Combinations of lsd1 inhibitors for the treatment of hematological malignancies

ABSTRACT

pharmaceutical compositions comprising them, and their use as medicaments, particularly for the treatment of hematological malignancies.

FIELD OF THE INVENTION

The instant invention relates to combinations of LSD1 inhibitors, particularly of ORY-1001 with other anticancer agents. The combinations are particularly useful for the treatment of hematological malignancies.

BACKGROUND OF THE INVENTION

Aberrant gene expression in affected tissue as compared to normal tissue is a common characteristic of many human diseases, including cancer. Gene expression patterns are controlled at multiple levels in the cell. Control of gene expression can occur through modifications of DNA: DNA promoter methylation is associated with suppression of gene expression. Several inhibitors of DNA methylation are approved for clinical use including the blockbuster Vidaza™ Another class of modifications involve histones which form the protein scaffold that DNA is normally associated with (coiled around) in eukaryotic cells. Histones play a crucial role in organizing DNA and the regulated coiling and uncoiling of DNA around the histones is critical in controlling gene expression—coiled DNA is typically not accessible for gene transcription. A number of histone modifications have been discovered including histone acetylation, histone lysine methylation, histone arginine methylation, histone ubiquinylation, and histone sumoylation, many of which modify accessibility to the associated DNA by the cells transcriptional machinery. These histone marks serve to recruit various protein complexes involved in transcription and repression. An increasing number of studies are painting an intricate picture of how various combinations of histone marks control gene expression in cell-type specific manner and a new term has been coined to capture this concept: the histone code.

The prototypical histone mark is histone acetylation. Histone acetyl transferase and histone deacetylases are the catalytic machines involved in modulation of this histone mark although typically these enzymes are parts of multiprotein complexes containing other proteins involved in reading and modifying histone marks. The components of these protein complexes are typically cell-type specific and typically comprise transcriptional regulators, repressors, co-repressors, receptors associated with gene expression modulation (e.g., estrogen or androgen receptor). Histone deacetylase inhibitors alter the histone acetylation profile of chromatin. Accordingly, histone deacetylase inhibitors like Vorinostat (SAHA), Trichostatin A (TSA), and many others have been shown to alter gene expression in various in vitro and in vivo animal models. Clinically, histone deacetylase inhibitors have demonstrated activity in the cancer setting and are being investigated for oncology indications as well as for neurological conditions and other diseases.

Another modification that is involved in regulating gene expression is histone methylation including lysine and arginine methylation. The methylation status of histone lysines has recently been shown to be important in dynamically regulating gene expression.

A group of enzymes known as histone lysine methyl transferases and histone lysine demethylases are involved in histone lysine modifications. One particular human histone lysine demethylase enzyme called Lysine Specific Demethylase-1 (LSD1) was recently discovered¹ to be involved in this crucial histone modification. LSD1 has a fair degree of structural similarity, and amino acid identity/homology to polyamine oxidases and monoamine oxidases, all of which (i.e., MAO-A, MAO-B and LSD1) are flavin dependent amine oxidases which catalyze the oxidation of nitrogen-hydrogen bonds and/or nitrogen carbon bonds. LSD1 has been recognized as an interesting target for the development of new drugs to treat cancer, neurological diseases and other conditions.

Cyclopropylamine containing compounds are known to inhibit a number of medically important targets including amine oxidases like Monoamine Oxidase A (MAO-A; or MAOA), Monoamine Oxidase B (MAO-B; or MAOB), and Lysine Specific Demethylase-1 (LSD1). Tranylcypromine (also known as 2-phenylcyclopropylamine), which is the active ingredient of Parnate® and one of the best known examples of a cyclopropylamine, is known to inhibit all of these enzymes. Since MAO-A inhibition may cause undesired side effects, it would be desirable to identify cyclopropylamine derivatives that exhibit potent LSD1 inhibitory activity while being devoid of or having substantially reduced MAO-A inhibitory activity.

In view of the lack of adequate treatments for conditions such as cancer, there is a desperate need for disease modifying drugs and drugs that work by inhibiting novel targets. There is thus a need for improved methods and compositions that can be used to treat hyperproliferative diseases, particularly hematological malignancies.

International Patent Application WO 2013/057322² discloses a number of LSD1 inhibitors, including the compound of formula (I):

also known as ORY-1001 or (trans)-N1-((1R,2S)-2-phenylcyclopropyl)cyclohexane-1,4-diamine.

SUMMARY OF THE INVENTION

The invention is based at least in part upon the discovery that additive or synergistic effects in inhibiting the growth of cancer cells can be achieved by administering the compound of formula (I), or a pharmaceutically acceptable salt thereof, in combination with certain other specific agents. The combination and methods may be useful in the treatment of hyperproliferative disorders, particularly hematological malignancies.

The instant invention relates to combinations of LSD1 inhibitors, particularly of the compound of formula (I) or a pharmaceutically acceptable salt thereof.

with one or more therapeutic agents selected from the group consisting of retinoic acid analogues, nucleoside analogues, DOT1L inhibitors, HDAC inhibitors, demethylating agents, FLT3 inhibitors, BCL2 inhibitors, MDM2 inhibitors, c-KIT inhibitors, BET inhibitors, anthracyclines, arsenic trioxide, hydroxyurea, and pharmaceutically acceptable salts thereof.

Accordingly, the present invention provides a combination comprising a compound of formula (I):

or a pharmaceutically acceptable salt thereof, and one or more therapeutic agents selected from the group consisting of retinoic acid analogues, nucleoside analogues, DOT1L inhibitors, HDAC inhibitors, demethylating agents, FLT3 inhibitors, BCL2 inhibitors, MDM2 inhibitors, c-KIT inhibitors, BET inhibitors, anthracyclines, arsenic trioxide, hydroxyurea, and pharmaceutically acceptable salts thereof.

In another aspect, the present invention is directed to a combination comprising a compound of formula (I):

or a pharmaceutically acceptable salt thereof, and one or more therapeutic agents selected from the group consisting of retinoic acid analogues, nucleoside analogues, DOT1L inhibitors, HDAC inhibitors, demethylating agents, FLT3 inhibitors, BCL2 inhibitors, MDM2 inhibitors, c-KIT inhibitors, BET inhibitors, anthracyclines, arsenic trioxide, hydroxyurea, and pharmaceutically acceptable salts thereof, for use in the treatment of a hyperproliferative disorder, particularly a hematological malignancy, including myeloid hematological malignancies and lymphoid hematological malignancies, e.g. as described in more detail below.

In another aspect, the present invention is directed to a method for treating a hyperproliferative disorder, particularly a hematological malignancy, in a patient in need thereof, comprising administering to said patient a therapeutically effective amount of a compound of formula (I):

or a pharmaceutically acceptable salt thereof, and a therapeutically effective amount of one or more therapeutic agents selected from the group consisting of retinoic acid analogues, nucleoside analogues, DOT1L inhibitors, HDAC inhibitors, demethylating agents, FLT3 inhibitors, BCL2 inhibitors, MDM2 inhibitors, c-KIT inhibitors, BET inhibitors, anthracyclines, arsenic trioxide, hydroxyurea, and pharmaceutically acceptable salts thereof. In certain embodiments, said hematological malignancy is a myeloid hematological malignancy. In certain embodiments, said hematological malignancy is a lymphoid hematological malignancy.

In another aspect, the present invention is directed to a method for treating a hyperproliferative disorder, particularly a hematological malignancy, in a patient in need thereof, comprising administering to said patient a therapeutically effective amount of combination comprising a compound of formula (I):

or a pharmaceutically acceptable salt thereof, and one or more therapeutic agents selected from the group consisting of retinoic acid analogues, nucleoside analogues, DOT1L inhibitors, HDAC inhibitors, demethylating agents, FLT3 inhibitors, BCL2 inhibitors, MDM2 inhibitors, c-KIT inhibitors, BET inhibitors, anthracyclines, arsenic trioxide, hydroxyurea, and pharmaceutically acceptable salts thereof. In certain embodiments, said hematological malignancy is a myeloid hematological malignancy. In certain embodiments, said hematological malignancy is a lymphoid hematological malignancy.

In another aspect, the present invention is directed to a method for treating a hyperproliferative disorder, particularly a hematological malignancy, in a patient in need thereof, comprising administering to said patient a pharmaceutical composition comprising a compound of formula (I):

or a pharmaceutically acceptable salt thereof, and one or more therapeutic agents selected from the group consisting of retinoic acid analogues, nucleoside analogues, DOT1L inhibitors, HDAC inhibitors, demethylating agents, FLT3 inhibitors, BCL2 inhibitors, MDM2 inhibitors, c-KIT inhibitors, BET inhibitors, anthracyclines, arsenic trioxide, hydroxyurea, and pharmaceutically acceptable salts thereof, and one or more pharmaceutically acceptable excipients. In certain embodiments, said hematological malignancy is a myeloid hematological malignancy. In certain embodiments, said hematological malignancy is a lymphoid hematological malignancy.

In another aspect, the present invention provides a pharmaceutical composition comprising a compound of formula (I):

or a pharmaceutically acceptable salt thereof, and one or more therapeutic agents selected from the group consisting of retinoic acid analogues, nucleoside analogues, DOT1L inhibitors, HDAC inhibitors, demethylating agents, FLT3 inhibitors, BCL2 inhibitors, MDM2 inhibitors, c-KIT inhibitors, BET inhibitors, anthracyclines, arsenic trioxide, hydroxyurea, and pharmaceutically acceptable salts thereof, and one or more pharmaceutically acceptable excipients.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1: Plate organization for 9×9 matrix assays used in Examples 1 and 2.

FIG. 2: Combination indexes calculated for the combo ORY-1001/ATRA in MV(4;11) (FIG. 2A) and MOLM-13 cells (FIG. 2B) following the procedure described in Example 1.2.2.1.

FIG. 3: Combination indexes calculated for the combo ORY-1001/ARA-C in MV(4;11) (FIG. 3A), OCI-AML3 (FIG. 3B) and MOLM-13 cells (FIG. 3C) following the procedure described in Example 1.2.3.1.

FIG. 4: Combination indexes calculated for the combo ORY-1001/EPZ5676 in MV(4;11) (FIG. 4A) and MOLM-13 cells (FIG. 4B) following the procedure described in Example 1.2.4.1.

FIG. 5: Combination indexes calculated for the combo ORY-1001/SAHA in MV(4;11) (FIG. 5A) and MOLM-13 cells (FIG. 5B) following the procedure described in Example 1.2.6.1.

FIG. 6: Combination indexes calculated for the combo ORY1001/Rocilinostat in MV(4;11) (FIG. 6A), OCI-AML3 (FIG. 6B) and MOLM-13 cells (FIG. 6C) following the procedure described in Example 1.2.7.1.

FIG. 7: Combination indexes calculated for the combo ORY-1001/Azacitidine in MV(4;11) (FIG. 7A) and MOLM-13 cells (FIG. 7B) following the procedure described in Example 1.2.9.1.

FIG. 8: Combination indexes calculated for the combo ORY-1001/Decitabine in MV(4;11) (FIG. 8A) and MOLM-13 cells (FIG. 8B) following the procedure described in Example 1.2.10.1.

FIG. 9: Combination indexes calculated for the combo ORY-1001/Quizartinib in MV(4;11) (FIG. 9A) and MOLM-13 cells (FIG. 9B) following the procedure described in Example 1.2.11.1.

FIG. 10: Combination indexes calculated for the combo ORY1001/ABT737 in MV(4;11) (FIG. 10A) and MOLM-13 cells (FIG. 10B) following the procedure described in Example 1.2.12.1.

FIG. 11: Combination indexes calculated for the combo ORY1001/Nutlin3A in MOLM-13 cells following the procedure described in Example 1.2.13.1.

FIG. 12: Combination indexes calculated for the combo ORY1001/Dasatinib in MV(4;11) cells following the procedure described in Example 1.2.14.

FIG. 13: Combination indexes calculated for the combo ORY1001/JQ1 in MV(4;11) cells following the procedure described in Example 1.2.15.

FIG. 14: Dose-response curve of MV(4;11) cells treated with Hydroxyurea (HU) in combination with ORY-1001, following the procedure described in Example 1.2.16.

FIG. 15: Dose-response curve of MV(4;11) cells treated with As₂O₃(Arsenic) in combination with ORY-1001, following the procedure described in Example 1.2.17.

FIG. 16: Combination indexes calculated for the combo ORY-1001/ARA-C in MOLT-4 cells following the procedure described in Example 2.2.2.

FIG. 17: Combination indexes calculated for the combo ORY-1001/SAHA in MOLT-4 cells following the procedure described in Example 2.2.3.

FIG. 18: Combination indexes calculated for the combo ORY1001/Rocilinostat in MOLT-4 cells following the procedure described in Example 2.2.4.

FIG. 19: Combination indexes calculated for the combo ORY-1001/Entinostat in MOLT-4 cells following the procedure described in Example 2.2.5.

FIG. 20: Combination indexes calculated for the combo ORY-1001/Azacitidine in MOLT-4 cells following the procedure described in Example 2.2.6.

FIG. 21: Combination indexes calculated for the combo ORY-1001/Decitabine in MOLT-4 cells following the procedure described in Example 2.2.7.

FIG. 22: Combination indexes calculated for the combo ORY1001/ABT737 in MOLT-4 cells following the procedure described in Example 2.2.8.

DETAILED DESCRIPTION OF THE INVENTION

The present invention is based upon the discovery that the compound of formula (I), or a pharmaceutically acceptable salt thereof, and other therapeutic agents, as described herein, can be used in combination to treat hematological malignancies, with superior results than those attained by treatment with the compound of formula (I) alone or the other therapeutic agent alone.

In detail, the present invention provides a combination comprising the compound of formula (I), or a pharmaceutically acceptable salt thereof, and one or more therapeutic agents selected from a retinoic acid analogue, a nucleoside analogue, a DOT1L inhibitor, a HDAC inhibitor, a demethylating agent, an FLT3 inhibitor, a BCL2 inhibitor, an MDM2 inhibitor, a c-KIT inhibitor, a BET inhibitor, an anthracycline, arsenic trioxide, hydroxyurea, and pharmaceutically acceptable salts thereof.

In another aspect, the present invention provides a combination comprising the compound of formula (I), or a pharmaceutically acceptable salt thereof, and one or more therapeutic agents selected from a retinoic acid analogue, a nucleoside analogue, a DOT1L inhibitor, a HDAC inhibitor, a demethylating agent, an FLT3 inhibitor, a BCL2 inhibitor, an MDM2 inhibitor, a c-KIT inhibitor, a BET inhibitor, an anthracycline, arsenic trioxide, hydroxyurea, and pharmaceutically acceptable salts thereof, for use as a therapeutically active substance.

In another aspect, the present invention is directed to a combination comprising the compound of formula (I), or a pharmaceutically acceptable salt thereof, and one or more therapeutic agents selected from the group consisting of retinoic acid analogues, nucleoside analogues, DOT1L inhibitors, HDAC inhibitors, demethylating agents, FLT3 inhibitors, BCL2 inhibitors, MDM2 inhibitors, c-KIT inhibitors, BET inhibitors, anthracyclines, arsenic trioxide, hydroxyurea, and pharmaceutically acceptable salts thereof, for use in the treatment of an hematological malignancy. In certain embodiments, said hematological malignancy is a myeloid hematological malignancy. In certain embodiments, said hematological malignancy is a lymphoid hematological malignancy.

In another aspect, the present invention is directed to a method for treating a hematological malignancy in a patient in need thereof, comprising administering a therapeutically effective amount of compound of formula (I), or a pharmaceutically acceptable salt thereof, and a therapeutically effective amount of one or more therapeutic agents selected from the group consisting of retinoic acid analogues, nucleoside analogues, DOT1L inhibitors, HDAC inhibitors, demethylating agents, FLT3 inhibitors, BCL2 inhibitors, MDM2 inhibitors, c-KIT inhibitors, BET inhibitors, anthracyclines, arsenic trioxide, hydroxyurea, and pharmaceutically acceptable salts thereof. In certain embodiments, said hematological malignancy is a myeloid hematological malignancy. In certain embodiments, said hematological malignancy is a lymphoid hematological malignancy.

In another aspect, the present invention is directed to a method for treating a hematological malignancy in a patient in need thereof, comprising administering to said patient a therapeutically effective amount of combination comprising the compound of formula (I), or a pharmaceutically acceptable salt thereof, and one or more therapeutic agents selected from the group consisting of retinoic acid analogues, nucleoside analogues, DOT1L inhibitors, HDAC inhibitors, demethylating agents, FLT3 inhibitors, BCL2 inhibitors, MDM2 inhibitors, c-KIT inhibitors, BET inhibitors, anthracyclines, arsenic trioxide, hydroxyurea, and pharmaceutically acceptable salts thereof. In certain embodiments, said hematological malignancy is a myeloid hematological malignancy. In certain embodiments, said hematological malignancy is a lymphoid hematological malignancy.

In another aspect, the present invention provides the use of a combination comprising the compound of formula (I), or a pharmaceutically acceptable salt thereof, and one or more therapeutic agents selected from a retinoic acid analogue, a nucleoside analogue, a DOT1L inhibitor, a HDAC inhibitor, a demethylating agent, an FLT3 inhibitor, a BCL2 inhibitor, an MDM2 inhibitor, a c-KIT inhibitor, a BET inhibitor, an anthracycline, arsenic trioxide, hydroxyurea, and pharmaceutically acceptable salts thereof, for the treatment of hematological malignancies. In certain embodiments, said hematological malignancy is a myeloid hematological malignancy. In certain embodiments, said hematological malignancy is a lymphoid hematological malignancy.

In a further aspect, the present invention provides the use of a combination comprising the compound of formula (I), or a pharmaceutically acceptable salt thereof, and one or more therapeutic agents selected from a retinoic acid analogue, a nucleoside analogue, a DOT1L inhibitor, a HDAC inhibitor, a demethylating agent, an FLT3 inhibitor, a BCL2 inhibitor, an MDM2 inhibitor, a c-KIT inhibitor, a BET inhibitor, an anthracycline, arsenic trioxide, hydroxyurea, and pharmaceutically acceptable salts thereof, for the preparation of a medicament for the treatment of hematological malignancies. In certain embodiments, said hematological malignancy is a myeloid hematological malignancy. In certain embodiments, said hematological malignancy is a lymphoid hematological malignancy.

In another aspect, the present invention is directed to a method for treating a hematological malignancy in a patient in need thereof, comprising administering to said patient a pharmaceutical composition comprising the compound of formula (I), or a pharmaceutically acceptable salt thereof, and one or more therapeutic agents selected from the group consisting of retinoic acid analogues, nucleoside analogues, DOT1L inhibitors, HDAC inhibitors, demethylating agents, FLT3 inhibitors, BCL2 inhibitors, MDM2 inhibitors, c-KIT inhibitors, BET inhibitors, anthracyclines, arsenic trioxide, hydroxyurea, and pharmaceutically acceptable salts thereof, and one or more pharmaceutically acceptable excipients. In certain embodiments, said hematological malignancy is a myeloid hematological malignancy. In certain embodiments, said hematological malignancy is a lymphoid hematological malignancy.

In a further aspect, the present invention provides a pharmaceutical composition comprising the compound of formula (I), or a pharmaceutically acceptable salt thereof, and one or more therapeutic agents selected from the group consisting of retinoic acid analogues, nucleoside analogues, DOT1L inhibitors, HDAC inhibitors, demethylating agents, FLT3 inhibitors, BCL2 inhibitors, MDM2 inhibitors, c-KIT inhibitors, BET inhibitors, anthracyclines, arsenic trioxide, hydroxyurea, and pharmaceutically acceptable salts thereof, and one or more pharmaceutically acceptable excipients.

ORY-1001:

The compound of formula (I)

[CAS Reg. No. 1431304-21-0], also known as ORY-1001 or (trans)-N1-((1R,2S)-2-phenylcyclopropyl)cyclohexane-1,4-diamine, has been described e.g. in Example 5 of International Patent Application WO 2013/057322². Pharmaceutically acceptable salts thereof are also described therein, including hydrochloride salts [CAS Reg. No. 1431303-72-8, dihydrochloride]. Most particular pharmaceutically acceptable salt is a dihydrochloride salt. The compound of formula (I) acts as a selective LSD1 inhibitor.

Retinoic Acid Analogues:

Tretinoin [CAS Reg. No. 302-79-4], also known and referred to as ATRA or all-trans retinoic acid, has been described e.g. in U.S. Pat. No. 2,709,712³ or in the Recommended INN List 11⁴. Tretinoin causes the immature promyelocytes to differentiate. ATRA is one of the current standards of care for treatment of acute leukemia.

ATRA derivatives reported in the literature with anticancer, particularly antileukemia activity, can also be used in the combinations of the invention.

Nucleoside Analogues:

Nucleoside analogues are nucleosides which contain a nucleic acid analogue and a sugar and are used as therapeutic drugs against a range of disorders, including some being used in chemotherapy. A preferred nucleoside analogue for use in the combinations of the invention is Cytarabine.

Cytarabine [CAS Reg. No. 147-94-4], also known and referred to as ARA-C or arabinofuranosyl cytidine, has been described e.g. in Chu M. Y. et al.⁵ or in the Recommended INN List 6⁶. Cytarabine converts rapidly into cytosine arabinoside triphosphate, which damages DNA when the cell cycle holds in the S phase during DNA synthesis. ARA-C is one of the current standards of care for treatment of acute leukemia, usually in combination with an anthracycline such as daunorubicin

Other nucleoside analogues that can be used in the combinations of the invention include, but are not limited to sapacitabine, clofarabine, elacytarabine, fludarabine, cytarabine ocfosfate, gemcitabine, 2-chloro-2-deoxyadenosine (also known as 2-CDA), troxacitabine, forodesine and nelarabine.

DOT1L Inhibitors:

DOT1L is a histone methyltransferase that has been reported to be involved in leukemia, particularly in certain subtypes of AML and ALL, and inhibitors of DOT1L are under development for the treatment of leukemia. Any known DOT1L inhibitor can in principle be used in the combinations of the invention. Examples of DOT1L inhibitors that can be used include without limitation pinometostat, EPZ-004777, and SGC-0946. A preferred DOT1L inhibitor for use in the combinations of the invention is Pinometostat.

Pinometostat [CAS Reg. No. 1380288-87-8], also known and referred to as EPZ-5676, has been described e.g. in International Patent Application WO 2012075381⁷ or in the Proposed INN List 112⁸. Pinometostat acts as DOT1L inhibitor.

EPZ-004777 [CAS Reg. No. 1338466-77-5], also known as 7-[5-Deoxy-5-[[3-[[[[4-(1,1-dimethylethyl)phenyl]amino]carbonyl]amino]propyl](1-methylethyl)amino]-β-D-ribofuranosyl]-7H-pyrrolo[2,3-d]pyrimidin-4-amine, has been described e.g. in Daigle S. R. et al.⁹. EPZ-004777 acts as DOT1L inhibitor.

SGC0496 (CAS Reg No. 1561178-17-3) is the compound 1-[3-[[[(2R,3S,4R,5R)-5-(4-Amino-5-bromo-7H-pyrrolo[2,3-d]pyrimidin-7-yl)-3,4-dihydroxytetrahydrofuran-2-yl]methyl](isopropyl)amino]propyl]-3-[4-(2,2-dimethylethyl)phenyl]urea, and has been described in Yu et al.¹⁰. SGC0496 has the following chemical structure:

HDAC Inhibitors

Histone deactetylase (HDAC) inhibitors are a class of compounds that interfere with the function of histone deacetylase which are approved or under clinical development for the treatment of several times of cancers. Any known HDAC inhibitor can in principle be used in the combinations of the invention. Preferred HDAC inhibitors for use in the combinations of the invention are Belinostat, Panobinostat, Vorinostat, Ricolinostat, Entinostat, Mocetinostat, Abexinostat, Resminostat, Givinostat or Quisinostat.

Vorinostat [CAS Reg. No. 149647-78-9], also known and referred to as SAHA or suberanilohydroxamic acid, has been described e.g. in International Patent Application WO 9307148¹¹ or in the Recommended INN List 56¹². Vorinostat acts as histone deacetylase (HDAC) inhibitor.

Ricolinostat [CAS Reg. No. 1316214-52-4], also known and referred to as Rocilinostat and ACY-1215, has been described e.g. in International Patent Application WO 2011091213¹³ or in the Recommended INN List 71¹⁴. Ricolinostat acts as histone deacetylase (HDAC) inhibitor.

Entinostat [CAS Reg. No. 209783-80-2], also known as SNDX-275, has been described e.g. in Japanese Patent Application JP 10152462¹⁵ or in the Recommended INN List 61¹⁶. Entinostat acts as histone deacetylase (HDAC) inhibitor.

Belinostat (CAS Reg No 866323-14-0), also known as (22E)-N-Hydroxy-3-[3-(phenylsulfamoyl)phenyl]prop-2-enamide, has been disclosed in WO 2009/040517¹⁷. The compound has the following chemical structure:

Panobinostat (CAS Reg No 404950-80-7), also known as (2E)-N-hydroxy-3-[4-({[2-(2-methyl-1H-indol-3-yl)ethyl]amino}methyl)phenyl]acrylamide, has been disclosed in WO 02/022577¹⁸. The compound has the following chemical structure:

Demethylating Agents

Also known as hypomethylating agents, these are drugs that inhibit DNA methylation, particularly by blocking the activity of DNA methyltransferase (DNMT inhibitors). Currently two members of this class (decitabine and azacitidine) are FDA-approved for the treatment of myelodysplastic syndrome and are being investigated for use in a number of tumors, including AML¹⁹. DNMT inhibitors that can be used according to the invention include but are not limited to:

Decitabine [CAS Reg. No. 2353-33-5], also known as 5-aza-2′-deoxycytidine, has been described e.g. in Wolfrom I. M. L. et al.²⁰ or in the Recommended INN List 30²¹.

Azacitidine [CAS Reg. No. 320-67-2] has been described e.g. in German Patent DE 1140941²² or in the Recommended INN List 19²³. Azacitidine is one of the current standards of care for treatment of acute leukemia.

Guadecitabine, also known as SGI-110. This compound is a decitabine linked via phosphodiester bond to a guanosine and acts as a prodrug of decitabine. Following metabolic activation by phosphorylation and incorporation into DNA, guadecitabine inhibits DNA methyltransferase, thereby causing genome-wide and non-specific hypomethylation and inducing cell cycle arrest at S-phase. This agent is resistant to cytidine deaminase, hence may result in gradual release of decitabine both extra- and intracellularly, leading to more prolonged exposures to decitabine.

Zebularine, 5-fluoro-2′-deoxycytidine, 2′-deoxy-5,6-dihydro-5,6-azacytidine, hydralazine, procainamide, hydralazine, EGCG and RG108 are other DNMT inhibitors that can be used in the combinations of the invention.

FLT3 Inhibitors:

FMS-related tyrosine kinase 3 (FLT3) is a proto-oncogene. Mutations of the FTL3 receptor can lead to the development of leukemia, and indeed is one of the most frequently mutated genes in AML. FLT3 inhibitors are being developed for the treatment of several types of cancers. Any known FLT3 inhibitor can in principle be used in the combinations of the invention. Preferred FLT3 inhibitors for use in the combinations of the invention include Quizartinib, Sorafenib, Sunitinib and Lestaurtinib.

Quizartinib [CAS Reg. No. 950769-58-1] has been described e.g. in International Patent Application WO 2007109120²⁴ or in the Recommended INN List 99²⁵.

BCL2 Inhibitors:

Bcl2 (B cell lymphoma 2) is considered an important antiapoptotic protein and is classified as an oncogene. Alterations in the BCL2 gene have been identified as a cause of a number of cancers and Bcl2 inhibitors are being developed as anticancer therapy. Any known Bcl2 inhibitor can be used in the combinations of the invention. Preferred Bcl2 inhibitors include ABT-737, Navitoclax (aka ABT-263), Venetoclax (aka ABT-199), and Obatoclax

ABT-737 [CAS Reg. No. 852808-04-9], also known as 4-[4-[[2-(4-chlorophenyl)phenyl]methyl]piperazin-1-yl]-N-[4-[[(2R)-4-(dimethylamino)-1-phenylsulfanylbutan-2-yl]amino]-3-nitrophenyl]sulfonylbenzamide, has been described e.g. in International Patent Application WO 2005049594²⁶.

Navitoclax [CAS Reg. No. 923564-51-6], also known as ABT-263 or 4-(4-{[2-(4-Chlorophenyl)-5,5-dimethyl-1-cyclohexen-1-yl]methyl}-1-piperazinyl)-N-[(4-{[(2R)-4-(4-morpholinyl)-1-(phenylsulfanyl)-2-butanyl]amino}-3-[(trifluoromethyl) sulfonyl]phenyl)-sulfonyl]benzamide, has been described e.g. in US 20070027135²⁷.

Obatoclax [CAS Reg. No. 803712-67-6], also known as 2-(2-((3,5-Dimethyl-1H-pyrrol-2-yl)methylene)-3-methoxy-2H-pyrrol-5-yl)-1H-indole, has been described e.g. in International Patent Application WO 2004106328²⁸.

Venetoclax [CAS Reg. No. 1257044-40-8], also known as ABT-199 or 4-[4-[[2-(4-Chlorophenyl)-4,4-dimethylcyclohex-1-en-1-yl]methyl]piperazin-1-yl]-N-[[3-nitro-4-[[(tetrahydro-2H-pyran-4-yl)methyl]amino]phenyl]sulfonyl]-2-[(1H-pyrrolo[2,3-b]pyridin-5-yl)oxy]benzamide, has been described e.g. in International Patent Application WO 2010138588²⁹.

MDM2 Inhibitors:

Mouse double minute 2 homolog (MDM2) is considered an important negative regulator of the p53 tumor suppressor, among other roles in cancer. Mdm2 inhibitors are compounds which inhibit the interaction between Mdm2 and p53 and include Nutlins, among others. A particularly preferred Mdm2 inhibitor is Nutlin-3A.

Nutlin-3A [CAS Reg. No. 675576-98-4], also known as 4-[[(4S,5R)-4,5-bis(4-chlorophenyl)-4,5-dihydro-2-[4-methoxy-2-(1-methylethoxy)phenyl]-1H-imidazol-1-yl]carbonyl]-2-piperazinone, has been described e.g. in US Patent Application US 20050282803³⁰.

c-KIT Inhibitors:

c-KIT (also known as Mast/stem cell growth factor receptor (SCGFR) or CD117) is a receptor tyrosine kinase protein that in humans is a proto-oncogene. Activating mutations in this gene are associated with a number of cancers, including acute myeloid leukemia. Any disclosed cKIT inhibitor can be used in the combinations of the invention. A suitable c-KIT inhibitor is dasatinib or imatinib.

Dasatinib (CAS Reg No 302962-49-8), is the compound N-(2-chloro-6-methylphenyl)-2-[[6-[4-(2-hydroxyethyl)-1-piperazinyl]-2-methyl-4-pyrimidinyl]amino]-5-thiazolecarboxamide, with formula:

Dasatinib is approved for first line use in patients with chronic myelogenous leukemia (CML) and acute lymphoblastic leukemia (ALL).

Imatinib (CAS Reg No 152459-95-5), is the compound 4-[(4-methylpiperazin-1-yl)methyl]-N-(4-methyl-3-{[4-(pyridin-3-yl)pyrimidin-2-yl]amino}phenyl)benzamide, with formula:

Imatinib is a tyrosine kinase inhibitor used in the treatment of multiple cancers, including Philadelphia-chromosome positive CML.

Bet Inhibitors:

BET inhibitors are a class of drugs with anti-cancer, immunosuppressive, and other effects currently in clinical trials. These molecules reversibly bind the bromodomains of Bromodomain and Extra-Terminal motif (BET) proteins BRD2, BRD3, BRD4, and BRDT, and prevent protein-protein interaction between BET proteins and acetylated histones and transcription factors. Any reported BET inhibitor can be used in the combinations of the invention. Examples of BET inhibitors include without limitation:

JQ1 (CAS Reg No 1268524-70-4) is (S)-tert-butyl 2-(4-(4-chlorophenyl)-2,3,9-trimethyl-6H-thieno[3,2-f][1,2,4]triazolo[4,3-a][1,4]diazepin-6-yl)acetate and is disclosed in WO 2011143651³¹.

GSK1210151A (I-BET 151) (CAS Reg No 1300031-49-5) is 7,3,5-dimethyl-4-isoxazolyl-1,3-dihydro-8-methoxy-1-[1R-1-(2-pyridinyl)ethyl]-2H-imidazo[4,5-c]quinolin-2-one and is disclosed in WO 2011054843³².

MS 436 (CAS Reg No 1395084-25-9) is 4-[(1E)-2-(2-amino-4-hydroxy-5-methylphenyl)diazenyl]-N-2-pyridinyl-benzenesulfonamide and is disclosed in WO 2012116170³³.

I-BET 762 (GSK525762) is:

OTX-015 (CAS Reg No 202590-98-5) is (6S)-4-(4-chlorophenyl)-N-(4-hydroxyphenyl)-2,3,9-trimethyl-6H-Thieno[3,2-f][1,2,4]triazolo[4,3-a][1,4]diazepine-6-acetamide and is disclosed in U.S. Pat. No. 5,712,274³⁴.

CPI-203 (CAS Reg No 1446144-04-2) is (6S)-4-(4-chlorophenyl)-2,3,9-trimethyl-6H-thieno[3,2-f][1,2,4]triazolo[4,3-a][1,4]diazepine-6-acetamide and has been disclosed in WO 2014134583³⁵.

GSK1324726A (I-BET726) (CAS Reg No 1300031-52-0) is 4-[(2S,4R)-1-acetyl-4-[(4-chlorophenyl)amino]-1,2,3,4-tetrahydro-2-methyl-6-quinolinyl]-benzoic acid and has been disclosed in WO 2011054843³⁶.

Other BET inhibitors that can be used in combination with a compound of formula (I) include ABBV-075, BAY1238097, CPI-0610 and TEN-010.

Anthracyclines:

Anthracyclines (or anthracycline antibiotics) are a class of drugs used in cancer chemotherapy derived from Streptomyces bacterium Streptomyces peucetius var. caesius. These compounds are used to treat many cancers, including leukemias. Examples of anthracyclines for use in the combinations of the invention include doxorubicin, idarubicin, and daunorubicin.

Anthracyclines such as daunorubicin, doxorubicin an idarubicin are commonly used to treat specific types of leukemia (e.g. acute myeloid leukemia and acute lymphocytic leukemia), usually in combination with other chemotherapy drugs such as cytarabine.

Arsenic Trioxide:

Arsenic trioxide is a chemotherapeutic agent approved by the US FDA for the treatment of acute promyelocytic leukemia that is unresponsive to “first line” agents, such as ATRA. It has been shown that arsenic trioxide induces cancer cells to undergo apoptosis. Use as a cytostatic in the treatment of refractory promyelocytic (M3) subtype of acute myeloid leukemia. The combination therapy of arsenic trioxide and all-trans retinoic acid (ATRA) has been approved by the FDA for treatment of certain leukemias. A liquid form of arsenic trioxide that can be administered orally has been developed.

Hydroxyurea:

Hydroxyurea (CAS Reg No. 127-07-1), also known as Hydroxycarbamide, is an antineoplastic drug used in myeloproliferative disorders, including CML. Hydroxycarbamide decreases the production of deoxyribonucleotides via inhibition of the enzyme ribonucleotide reductase by scavenging tyrosyl free radicals as they are involved in the reduction NDPs.

ATRA, ARA-C (optionally in combination with an anthracycline such as daunorubicin or idarubicin) and Azacitidine are the current standards of care for treatment of acute leukemia.

In certain embodiments, the retinoic acid analogue is tretinoin.

In certain embodiments, the nucleoside analogue is cytarabine.

In certain embodiments, the DOT1L inhibitor is selected from pinometostat and EPZ-004777.

In certain embodiments, the HDAC inhibitor is selected from vorinostat, ricolinostat, and entinostat.

In certain embodiments, the DNMT inhibitor is selected from decitabine, and azacitidine.

In certain embodiments, the FLT3 inhibitor is quizartinib.

In certain embodiments, the BCL2 inhibitor is ABT-737.

In certain embodiments, the MDM2 inhibitor is Nutlin-3A.

In certain embodiments, the c-KIT inhibitor is dasatinib.

In certain embodiments, the BET inhibitor is JQ-1.

In certain embodiments, the anthracycline is daunorubicin.

Another embodiment relates to a combination comprising the compound of formula (I) or a pharmaceutically acceptable salt thereof, and one or more therapeutic agents selected from tretinoin, cytarabine, sapacitabine, clofarabine, elacytarabine, fludarabine, cytarabine ocfosfate, gemcitabine, 2-chloro-2-deoxyadenosine (also known as 2-CDA), troxacitabine, forodesine, nelarabine, pinometostat, EPZ-004777, SGC-0946, Belinostat, Panobinostat, Vorinostat, Ricolinostat, Entinostat, Mocetinostat, Abexinostat, Resminostat, Givinostat, Quisinostat, decitabine, azacitidine, guadecitabine, Quizartinib, Sorafenib, Sunitinib, Lestaurtinib, ABT-737, Navitoclax, Venetoclax, Obatoclax, Nutlin-3A, dasatinib, imatinib, JQ1, GSK1210151A, MS 436, GSK525762, OTX-015, CPI-203, GSK1324726A, daunorubicin, doxorubicin, idarubicin, arsenic trioxide, hydroxyurea, and pharmaceutically acceptable salts thereof. In a particular embodiment, the combination comprises the compound of formula (I) or a pharmaceutically acceptable salt thereof, and one or more therapeutic agents selected from tretinoin, cytarabine, pinometostat, EPZ-00477, Vorinostat, Ricolinostat, Entinostat, decitabine, azacitidine, Quizartinib, ABT-737, Nutlin-3A, dasatinib, JQ1, daunorubicin, arsenic trioxide, hydroxyurea, and pharmaceutically acceptable salts thereof.

Another embodiment relates to a pharmaceutical composition comprising the compound of formula (I) or a pharmaceutically acceptable salt thereof, and one or more therapeutic agents selected from tretinoin, cytarabine, sapacitabine, clofarabine, elacytarabine, fludarabine, cytarabine ocfosfate, gemcitabine, 2-chloro-2-deoxyadenosine (also known as 2-CDA), troxacitabine, forodesine, nelarabine, pinometostat, EPZ-004777, SGC-0946, Belinostat, Panobinostat, Vorinostat, Ricolinostat, Entinostat, Mocetinostat, Abexinostat, Resminostat, Givinostat, Quisinostat, decitabine, azacitidine, guadecitabine, Quizartinib, Sorafenib, Sunitinib, Lestaurtinib, ABT-737, Navitoclax, Venetoclax, Obatoclax, Nutlin-3A, dasatinib, imatinib, JQ1, GSK1210151A, MS 436, GSK525762, OTX-015, CPI-203, GSK1324726A, daunorubicin, doxorubicin, idarubicin, arsenic trioxide, hydroxyurea, and pharmaceutically acceptable salts thereof, and one or more pharmaceutically acceptable excipient. In a particular embodiment, the pharmaceutical composition comprises the compound of formula (I) or a pharmaceutically acceptable salt thereof, and one or more therapeutic agents selected from tretinoin, cytarabine, pinometostat, EPZ-00477, Vorinostat, Ricolinostat, Entinostat, decitabine, azacitidine, Quizartinib, ABT-737, Nutlin-3A, dasatinib, JQ1, daunorubicin, arsenic trioxide, hydroxyurea, and pharmaceutically acceptable salts thereof, and one or more pharmaceutically acceptable excipient.

Another embodiment relates to a combination comprising the compound of formula (I) or a pharmaceutically acceptable salt thereof, and one or more therapeutic agents selected from tretinoin, cytarabine, sapacitabine, clofarabine, elacytarabine, fludarabine, cytarabine ocfosfate, gemcitabine, 2-chloro-2-deoxyadenosine (also known as 2-CDA), troxacitabine, forodesine, nelarabine, pinometostat, EPZ-004777, SGC-0946, Belinostat, Panobinostat, Vorinostat, Ricolinostat, Entinostat, Mocetinostat, Abexinostat, Resminostat, Givinostat, Quisinostat, decitabine, azacitidine, guadecitabine, Quizartinib, Sorafenib, Sunitinib, Lestaurtinib, ABT-737, Navitoclax, Venetoclax, Obatoclax, Nutlin-3A, dasatinib, imatinib, JQ1, GSK1210151A, MS 436, GSK525762, OTX-015, CPI-203, GSK1324726A, daunorubicin, doxorubicin, idarubicin, arsenic trioxide, hydroxyurea, and pharmaceutically acceptable salts thereof, for use as therapeutically active substance. In a particular embodiment, the combination comprises the compound of formula (I) or a pharmaceutically acceptable salt thereof, and one or more therapeutic agents selected from tretinoin, cytarabine, pinometostat, EPZ-00477, Vorinostat, Ricolinostat, Entinostat, decitabine, azacitidine, Quizartinib, ABT-737, Nutlin-3A, dasatinib, JQ1, daunorubicin, arsenic trioxide, hydroxyurea, and pharmaceutically acceptable salts thereof, for use as a therapeutically active substance.

Another embodiment relates to a combination comprising the compound of formula (I) or a pharmaceutically acceptable salt thereof, and one or more therapeutic agents selected from tretinoin, cytarabine, sapacitabine, clofarabine, elacytarabine, fludarabine, cytarabine ocfosfate, gemcitabine, 2-chloro-2-deoxyadenosine (also known as 2-CDA), troxacitabine, forodesine, nelarabine, pinometostat, EPZ-004777, SGC-0946, Belinostat, Panobinostat, Vorinostat, Ricolinostat, Entinostat, Mocetinostat, Abexinostat, Resminostat, Givinostat, Quisinostat, decitabine, azacitidine, guadecitabine, Quizartinib, Sorafenib, Sunitinib, Lestaurtinib, ABT-737, Navitoclax, Venetoclax, Obatoclax, Nutlin-3A, dasatinib, imatinib, JQ1, GSK1210151A, MS 436, GSK525762, OTX-015, CPI-203, GSK1324726A, daunorubicin, doxorubicin, idarubicin, arsenic trioxide, hydroxyurea, and pharmaceutically acceptable salts thereof, for use in the treatment of a hyperproliferative disorder. In a particular embodiment, the combination comprises the compound of formula (I) or a pharmaceutically acceptable salt thereof, and one or more therapeutic agents selected from tretinoin, cytarabine, pinometostat, EPZ-00477, Vorinostat, Ricolinostat, Entinostat, decitabine, azacitidine, Quizartinib, ABT-737, Nutlin-3A, dasatinib, JQ1, daunorubicin, arsenic trioxide, hydroxyurea, and pharmaceutically acceptable salts thereof, for use in the treatment of a hematological malignancy. In certain embodiments, said hematological malignancy is a myeloid hematological malignancy. In certain embodiments, said hematological malignancy is a lymphoid hematological malignancy.

Another embodiment relates to a method for the treatment of a hematological malignancy in a patient in need thereof, which method comprises administering a therapeutically effective amount of combination comprising the compound of formula (I) or a pharmaceutically acceptable salt thereof, and one or more therapeutic agents selected from tretinoin, cytarabine, sapacitabine, clofarabine, elacytarabine, fludarabine, cytarabine ocfosfate, gemcitabine, 2-chloro-2-deoxyadenosine (also known as 2-CDA), troxacitabine, forodesine, nelarabine, pinometostat, EPZ-004777, SGC-0946, Belinostat, Panobinostat, Vorinostat, Ricolinostat, Entinostat, Mocetinostat, Abexinostat, Resminostat, Givinostat, Quisinostat, decitabine, azacitidine, guadecitabine, Quizartinib, Sorafenib, Sunitinib, Lestaurtinib, ABT-737, Navitoclax, Venetoclax, Obatoclax, Nutlin-3A, dasatinib, imatinib, JQ1, GSK1210151A, MS 436, GSK525762, OTX-015, CPI-203, GSK1324726A, daunorubicin, doxorubicin, idarubicin, arsenic trioxide, hydroxyurea, and pharmaceutically acceptable salts thereof to said patient. In a particular embodiment, the method comprises administering a therapeutically effective amount of combination comprising the compound of formula (I) or a pharmaceutically acceptable salt thereof, and one or more therapeutic agents selected from tretinoin, cytarabine, pinometostat, EPZ-00477, Vorinostat, Ricolinostat, Entinostat, decitabine, azacitidine, Quizartinib, ABT-737, Nutlin-3A, dasatinib, JQ1, daunorubicin, arsenic trioxide, hydroxyurea, and pharmaceutically acceptable salts thereof. In certain embodiments, said hematological malignancy is a myeloid hematological malignancy. In certain embodiments, said hematological malignancy is a lymphoid hematological malignancy.

Another embodiment relates to the use of a combination comprising the compound of formula (I) or a pharmaceutically acceptable salt thereof, and one or more therapeutic agents selected from tretinoin, cytarabine, sapacitabine, clofarabine, elacytarabine, fludarabine, cytarabine ocfosfate, gemcitabine, 2-chloro-2-deoxyadenosine (also known as 2-CDA), troxacitabine, forodesine, nelarabine, pinometostat, EPZ-004777, SGC-0946, Belinostat, Panobinostat, Vorinostat, Ricolinostat, Entinostat, Mocetinostat, Abexinostat, Resminostat, Givinostat, Quisinostat, decitabine, azacitidine, guadecitabine, Quizartinib, Sorafenib, Sunitinib, Lestaurtinib, ABT-737, Navitoclax, Venetoclax, Obatoclax, Nutlin-3A, dasatinib, imatinib, JQ1, GSK1210151A, MS 436, GSK525762, OTX-015, CPI-203, GSK1324726A, daunorubicin, doxorubicin, idarubicin, arsenic trioxide, hydroxyurea, and pharmaceutically acceptable salts thereof for the treatment of a hematological malignancy. In a particular embodiment, the combination comprises the compound of formula (I) or a pharmaceutically acceptable salt thereof, and one or more therapeutic agents selected from tretinoin, cytarabine, pinometostat, EPZ-00477, Vorinostat, Ricolinostat, Entinostat, decitabine, azacitidine, Quizartinib, ABT-737, Nutlin-3A, dasatinib, JQ1, daunorubicin, arsenic trioxide, hydroxyurea, and pharmaceutically acceptable salts thereof for the treatment of a hematological malignancy. In certain embodiments, said hematological malignancy is a myeloid hematological malignancy. In certain embodiments, said hematological malignancy is a lymphoid hematological malignancy.

Another embodiment relates to the use of a combination comprising the compound of formula (I) or a pharmaceutically acceptable salt thereof, and one or more therapeutic agents selected from tretinoin, cytarabine, sapacitabine, clofarabine, elacytarabine, fludarabine, cytarabine ocfosfate, gemcitabine, 2-chloro-2-deoxyadenosine (also known as 2-CDA), troxacitabine, forodesine, nelarabine, pinometostat, EPZ-004777, SGC-0946, Belinostat, Panobinostat, Vorinostat, Ricolinostat, Entinostat, Mocetinostat, Abexinostat, Resminostat, Givinostat, Quisinostat, decitabine, azacitidine, guadecitabine, Quizartinib, Sorafenib, Sunitinib, Lestaurtinib, ABT-737, Navitoclax, Venetoclax, Obatoclax, Nutlin-3A, dasatinib, imatinib, JQ1, GSK1210151A, MS 436, GSK525762, OTX-015, CPI-203, GSK1324726A, daunorubicin, doxorubicin, idarubicin, arsenic trioxide, hydroxyurea, and pharmaceutically acceptable salts thereof for the preparation of medicaments useful in the treatment of a hematological malignancy. In a particular embodiment, the invention relates to the use of a combination comprising the compound of formula (I) or a pharmaceutically acceptable salt thereof, and one or more therapeutic agents selected from tretinoin, cytarabine, pinometostat, EPZ-00477, Vorinostat, Ricolinostat, Entinostat, decitabine, azacitidine, Quizartinib, ABT-737, Nutlin-3A, dasatinib, JQ1, daunorubicin, arsenic trioxide, hydroxyurea, and pharmaceutically acceptable salts thereof for the preparation of medicaments useful in the treatment of a hematological malignancy disorder. In certain embodiments, said hematological malignancy is a myeloid hematological malignancy. In certain embodiments, said hematological malignancy is a lymphoid hematological malignancy.

Another embodiment relates to a combination as described herein and one or more pharmaceutically acceptable excipient.

Another embodiment relates to a combination as described herein for use as therapeutically active substance.

Another embodiment relates to a combination as described herein for use in the treatment of a hematological malignancy. In certain embodiments, said hematological malignancy is a myeloid hematological malignancy. In certain embodiments, said hematological malignancy is a lymphoid hematological malignancy.

Another embodiment relates to a method for the treatment of a hematological malignancy, which method comprises administering an effective amount of a combination as described herein to a human being or animal. In certain embodiments, said hematological malignancy is a myeloid hematological malignancy. In certain embodiments, said hematological malignancy is a lymphoid hematological malignancy.

Another embodiment relates to the use of a combination as described herein for the treatment of a hematological malignancy. In certain embodiments, said hematological malignancy is a myeloid hematological malignancy. In certain embodiments, said hematological malignancy is a lymphoid hematological malignancy.

Another embodiment relates to the use of a combination as described herein for the preparation of medicaments useful in the treatment of a hematological malignancy. In certain embodiments, said hematological malignancy is a myeloid hematological malignancy. In certain embodiments, said hematological malignancy is a lymphoid hematological malignancy.

In certain embodiments, the hematological malignancy is related to LSD1 or is modulated by LSD1 inhibitors.

In certain embodiments, the hematological malignancy is a myeloid hematological malignancy.

In certain embodiments, the hematological malignancy is acute myeloid leukemia (AML).

In certain embodiments, the hematological malignancy is a lymphoid hematological malignancy.

In certain embodiments, the hematological malignancy is acute lymphoid leukemia (ALL).

In certain embodiments, the combination comprises a compound of formula (I) or a pharmaceutically acceptable salt thereof and a retinoic acid analogue or a pharmaceutically acceptable salt thereof.

In certain embodiments, the combination comprises a compound of formula (I) or a pharmaceutically acceptable salt thereof and a nucleoside analogue or a pharmaceutically acceptable salt thereof.

In certain embodiments, the combination comprises a compound of formula (I) or a pharmaceutically acceptable salt thereof and a DOT1L inhibitor or a pharmaceutically acceptable salt thereof.

In certain embodiments, the combination comprises a compound of formula (I) or a pharmaceutically acceptable salt thereof and a HDAC inhibitor or a pharmaceutically acceptable salt thereof.

In certain embodiments, the combination comprises a compound of formula (I) or a pharmaceutically acceptable salt thereof and a DNMT inhibitor or a pharmaceutically acceptable salt thereof.

In certain embodiments, the combination comprises a compound of formula (I) or a pharmaceutically acceptable salt thereof and a FLT3 inhibitor or a pharmaceutically acceptable salt thereof.

In certain embodiments, the combination comprises a compound of formula (I) or a pharmaceutically acceptable salt thereof and a BCL2 inhibitor or a pharmaceutically acceptable salt thereof.

In certain embodiments, the combination comprises a compound of formula (I) or a pharmaceutically acceptable salt thereof and a MDM2 inhibitor or a pharmaceutically acceptable salt thereof.

In certain embodiments, the combination comprises a compound of formula (I) or a pharmaceutically acceptable salt thereof and a c-KIT inhibitor or a pharmaceutically acceptable salt thereof.

In certain embodiments, the combination comprises a compound of formula (I) or a pharmaceutically acceptable salt thereof and a BET inhibitor or a pharmaceutically acceptable salt thereof.

In certain embodiments, the combination comprises a compound of formula (I) or a pharmaceutically acceptable salt thereof and an anthracycline or a pharmaceutically acceptable salt thereof.

In certain embodiments, the combination comprises a compound of formula (I) or a pharmaceutically acceptable salt thereof and arsenic trioxide.

In certain embodiments, the combination comprises a compound of formula (I) or a pharmaceutically acceptable salt thereof and hydroxyurea.

In certain embodiments, the combination comprises a compound of formula (I) or a pharmaceutically acceptable salt thereof and tretinoin or a pharmaceutically acceptable salt thereof.

In certain embodiments, the combination comprises a compound of formula (I) or a pharmaceutically acceptable salt thereof and cytarabine or a pharmaceutically acceptable salt thereof.

In certain embodiments, the combination comprises a compound of formula (I) or a pharmaceutically acceptable salt thereof and pinometostat or a pharmaceutically acceptable salt thereof.

In certain embodiments, the combination comprises a compound of formula (I) or a pharmaceutically acceptable salt thereof and EPZ-004777 or a pharmaceutically acceptable salt thereof.

In certain embodiments, the combination comprises a compound of formula (I) or a pharmaceutically acceptable salt thereof and vorinostat or a pharmaceutically acceptable salt thereof.

In certain embodiments, the combination comprises a compound of formula (I) or a pharmaceutically acceptable salt thereof and ricolinostat or a pharmaceutically acceptable salt thereof.

In certain embodiments, the combination comprises a compound of formula (I) or a pharmaceutically acceptable salt thereof and entinostat or a pharmaceutically acceptable salt thereof.

In certain embodiments, the combination comprises a compound of formula (I) or a pharmaceutically acceptable salt thereof and decitabine or a pharmaceutically acceptable salt thereof.

In certain embodiments, the combination comprises a compound of formula (I) or a pharmaceutically acceptable salt thereof and azacitidine or a pharmaceutically acceptable salt thereof.

In certain embodiments, the combination comprises a compound of formula (I) or a pharmaceutically acceptable salt thereof and quizartinib or a pharmaceutically acceptable salt thereof.

In certain embodiments, the combination comprises a compound of formula (I) or a pharmaceutically acceptable salt thereof and ABT-737 or a pharmaceutically acceptable salt thereof.

In certain embodiments, the combination comprises a compound of formula (I) or a pharmaceutically acceptable salt thereof and Nutlin-3A or a pharmaceutically acceptable salt thereof.

In certain embodiments, the combination comprises a compound of formula (I) or a pharmaceutically acceptable salt thereof and dasatinib or a pharmaceutically acceptable salt thereof.

In certain embodiments, the combination comprises a compound of formula (I) or a pharmaceutically acceptable salt thereof and imatinib or a pharmaceutically acceptable salt thereof.

In certain embodiments, the combination comprises a compound of formula (I) or a pharmaceutically acceptable salt thereof and JQ1 or a pharmaceutically acceptable salt thereof.

In certain embodiments, the combination comprises a compound of formula (I) or a pharmaceutically acceptable salt thereof and daunorubicin or a pharmaceutically acceptable salt thereof.

In certain embodiments, the combination comprises a compound of formula (I) or a pharmaceutically acceptable salt thereof and idarubicin or a pharmaceutically acceptable salt thereof.

In certain embodiments, the combination comprises a compound of formula (I) or a pharmaceutically acceptable salt thereof, cytarabine and an anthracycline, preferably selected from daunorubicin, idarubicin, and pharmaceutically acceptable salts thereof.

In certain embodiments, the pharmaceutically acceptable salt of the compound of formula (I) as described above is a di-hydrochloride salt.

In the methods according to the invention described herein, the patient is a human being or animal, preferably a human being.

Unless otherwise defined, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which this invention belongs. Although methods and materials similar or equivalent to those described herein can be used in the practice or testing of the invention, suitable methods and materials are described below.

All publications, patent applications, patents, and other references mentioned herein are incorporated by reference in their entirety.

The nomenclature used in this Application is based on IUPAC systematic nomenclature, unless indicated otherwise.

Any open valency appearing on a carbon, oxygen, sulfur or nitrogen atom in the structures herein indicates the presence of a hydrogen, unless indicated otherwise.

The term “optional” or “optionally” denotes that a subsequently described event or circumstance can but need not occur, and that the description includes instances where the event or circumstance occurs and instances in which it does not.

“The term “pharmaceutically acceptable salts” denotes salts which are not biologically or otherwise undesirable. Pharmaceutically acceptable salts include both acid and base addition salts.

The term “pharmaceutically acceptable acid addition salt” denotes those pharmaceutically acceptable salts formed with inorganic acids such as hydrochloric acid, hydrobromic acid, sulfuric acid, nitric acid, carbonic acid, phosphoric acid, and organic acids selected from aliphatic, cycloaliphatic, aromatic, araliphatic, heterocyclic, carboxylic, and sulfonic classes of organic acids such as formic acid, acetic acid, propionic acid, glycolic acid, gluconic acid, lactic acid, pyruvic acid, oxalic acid, malic acid, maleic acid, maloneic acid, succinic acid, fumaric acid, tartaric acid, citric acid, aspartic acid, ascorbic acid, glutamic acid, anthranilic acid, benzoic acid, cinnamic acid, mandelic acid, embonic acid, phenylacetic acid, methanesulfonic acid, ethanesulfonic acid, p-toluenesulfonic acid, and salicyclic acid.

The term “pharmaceutically acceptable base addition salt” denotes those pharmaceutically acceptable salts formed with an organic or inorganic base. Examples of acceptable inorganic bases include sodium, potassium, ammonium, calcium, magnesium, iron, zinc, copper, manganese, and aluminum salts. Salts derived from pharmaceutically acceptable organic nontoxic bases includes salts of primary, secondary, and tertiary amines, substituted amines including naturally occurring substituted amines, cyclic amines and basic ion exchange resins, such as isopropylamine, trimethylamine, diethylamine, triethylamine, tripropylamine, ethanolamine, 2-diethylaminoethanol, trimethamine, dicyclohexylamine, lysine, arginine, histidine, caffeine, procaine, hydrabamine, choline, betaine, ethylenediamine, glucosamine, methylglucamine, theobromine, purines, piperizine, piperidine, N-ethylpiperidine, and polyamine resins.

Stereochemical definitions and conventions used herein generally follow S. P. Parker³⁷; and Eliel, E. and Wilen, S.³⁸. In describing an optically active compound, the prefixes D and L, or R and S, are used to denote the absolute configuration of the molecule about its chiral center(s). The substituents attached to the chiral center under consideration are ranked in accordance with the Sequence Rule of Cahn, Ingold and Prelog³⁹. The prefixes D and L or (+) and (−) are employed to designate the sign of rotation of plane-polarized light by the compound, with (−) or L designating that the compound is levorotatory. A compound prefixed with (+) or D is dextrorotatory.

The terms “pharmaceutical composition” and “pharmaceutical formulation” (or “formulation”) are used interchangeably and denote a mixture or solution comprising a therapeutically effective amount of an active pharmaceutical ingredient together with pharmaceutically acceptable excipients to be administered to a mammal, e.g., a human in need thereof.

The term “pharmaceutically acceptable” denotes an attribute of a material which is useful in preparing a pharmaceutical composition that is generally safe, non-toxic, and neither biologically nor otherwise undesirable and is acceptable for veterinary as well as human pharmaceutical use.

The terms “pharmaceutically acceptable excipient”, “pharmaceutically acceptable carrier” and “therapeutically inert excipient” can be used interchangeably and denote any pharmaceutically acceptable ingredient in a pharmaceutical composition having no therapeutic activity and being non-toxic to the subject administered, such as disintegrators, binders, fillers, solvents, buffers, tonicity agents, stabilizers, antioxidants, surfactants, carriers, diluents or lubricants used in formulating pharmaceutical products.

The term “inhibitor” denotes a compound which competes with, reduces or prevents the binding of a particular ligand to a particular receptor or enzyme and/or which reduces or prevents the activity of a particular protein, e.g. of a receptor or an enzyme.

An “individual” or “subject” is a mammal. Mammals include, but are not limited to, domesticated animals (e.g., cows, sheep, cats, dogs, and horses), primates (e.g., humans and non-human primates such as monkeys), rabbits, and rodents (e.g., mice and rats). In certain embodiments, the individual or subject is a human.

The term “animal” as used herein comprises human beings and non-human animals. In one embodiment, a “non-human animal” is a mammal, for example a rodent such as rat or a mouse.

In one embodiment, a non-human animal is a mouse.

The term “half maximal effective concentration” (EC₅₀) denotes the plasma concentration of a particular compound or molecule required for obtaining 50% of the maximum of a particular effect in vivo.

The term “therapeutically effective amount” (or “effective amount”) denotes an amount of a compound or molecule of the present invention that, when administered to a subject, (i) treats or prevents the particular disease, condition or disorder, (ii) attenuates, ameliorates or eliminates one or more symptoms of the particular disease, condition, or disorder, or (iii) prevents or delays the onset of one or more symptoms of the particular disease, condition or disorder described herein. The therapeutically effective amount will vary depending on the compound, the disease state being treated, the severity of the disease treated, the age and relative health of the subject, the route and form of administration, the judgment of the attending medical or veterinary practitioner, and other factors.

The term “treating” or “treatment” of a disease state includes inhibiting the disease state, i.e., arresting the development of the disease state or its clinical symptoms, or relieving the disease state, i.e., causing temporary or permanent regression of the disease state or its clinical symptoms. The term “translocation” or “chromosome translocation” denotes a type of chromosome abnormality caused by rearrangement of parts between nonhomologous chromosomes. Translocations can be balanced (in an even exchange of material with no genetic information extra or missing) or unbalanced (where the exchange of chromosome material is unequal resulting in extra or missing genes). Chromosomal translocations can occur either in gametogenesis, due to errors in meiosis, or in cellular division of somatic cells, due to errors in mitosis. The former results in a chromosomal abnormality featured in all cells of the offspring, as in translocation carriers. Somatic translocations, on the other hand, result in abnormalities featured only in the affected cell line.

The term “rearrangement” or “chromosomal rearrangement” denotes a type of chromosome abnormality caused by a change in the structure of the native chromosome through deletions, duplications, inversions, or translocations. Rearrangements are caused by a breakage in the DNA double helices at two different locations, followed by a rejoining of the broken ends to produce a new chromosomal arrangement of genes, different from the gene order of the chromosomes before they were broken. “Complex chromosomal rearrangements” (CCR) denote structural chromosomal rearrangements with at least three breakpoints with exchange of genetic material between two or more chromosomes.

Another embodiment provides pharmaceutical compositions or medicaments comprising the combinations of the compound of formula (I) as described herein and a pharmaceutically acceptable excipient, as well as methods of using the compound of formula (I) to prepare such combinations, compositions and medicaments.

Compositions are formulated, dosed, and administered in a fashion consistent with good medical practice. Factors for consideration in this context include the particular disorder being treated, the particular mammal being treated, the clinical condition of the individual patient, the cause of the disorder, the site of delivery of the agent, the method of administration, the scheduling of administration, and other factors known to medical practitioners.

The compound of formula (I) and the other therapeutic agent for use in the combinations as described herein as well as the pharmaceutical compositions as described herein may be administered by any suitable means, including oral, topical (including buccal and sublingual), rectal, vaginal, transdermal, parenteral, subcutaneous, intraperitoneal, intrapulmonary, intradermal, intrathecal and epidural and intranasal, and, if desired for local treatment, intralesional administration. Parenteral infusions include intramuscular, intravenous, intraarterial, intraperitoneal, or subcutaneous administration.

The compound of formula (I) and the other therapeutic agent for use in the combinations as described herein as well as the pharmaceutical compositions as described herein may be administered in any convenient administrative form, e.g., tablets, powders, capsules, solutions, dispersions, suspensions, syrups, sprays, suppositories, gels, emulsions, patches, etc. Such compositions may comprise components conventional in pharmaceutical preparations, e.g., diluents, carriers, pH modifiers, preservatives, solubilizers, stabilizers, wetting agents, emulsifiers, sweeteners, colorants, flavorants, salts for varying the osmotic pressure, buffers, masking agents, antioxidants, and further active agents. They can also comprise still other therapeutically valuable substances.

A typical formulation is prepared by mixing the compound of formula (I) or the therapeutic agent as described herein or the combination as described herein and a pharmaceutically acceptable excipient. Suitable excipients are well known to those skilled in the art and are described in detail in, e.g., Ansel H. C. et al.⁴⁰, Gennaro A. R. et al.⁴¹, and Rowe R. C.⁴². The formulations may also include one or more buffers, stabilizing agents, surfactants, wetting agents, lubricating agents, emulsifiers, suspending agents, preservatives, antioxidants, opaquing agents, glidants, processing aids, colorants, sweeteners, perfuming agents, flavoring agents, diluents and other known additives to provide an elegant presentation of the drug (i.e., a compound of the present invention or pharmaceutical composition thereof) or aid in the manufacturing of the pharmaceutical product (i.e., medicament).

The dosage at the compound of formula (I) and the other therapeutic agents as described herein can be administered can vary within wide limits and will, of course, be fitted to the individual requirements in each particular case.

As described herein, the compound of formula (I) is a highly potent active pharmaceutical ingredient (HPAPI). The anticipated daily dose is thus very low, i.e. lower than 10 mg per day. Accordingly, the drug load in a solid form will also be very low, i.e. less than 10 mg of API per 100 mg of tablet.

In general, in the case of oral administration a daily dosage of about 0.01 to 10 mg per person of the compound of formula (I) as described herein should be appropriate, although the above upper limit can also be exceeded when necessary.

The additional compound of the combination may be administered in amounts that are effective for the purpose intended. Suitable dosages for any of the above coadministered agents are those presently used and may be lowered due to the combined action (synergy) of the newly identified combinations, such as to increase the therapeutic index or mitigate toxicity or other side-effects or consequences.

An example of a suitable oral dosage form for a compound of formula (I) is a tablet comprising about 0.01 mg to 10 mg of a compound of formula (I) as described herein compounded with about 90 to 30 mg anhydrous lactose, about 5 to 40 mg sodium croscarmellose, about 5 to 30 mg polyvinylpyrrolidone (PVP) K30, and about 1 to 10 mg magnesium stearate. The powdered ingredients are first mixed together and then mixed with a solution of the PVP. The resulting composition can be dried, granulated, mixed with the magnesium stearate and compressed to tablet form using conventional equipment.

The combinations as described herein may be administered as a simultaneous or sequential regimen. When administered sequentially, the combination may be administered in two or more administrations. The combined administration includes coadministration, using separate formulation, and consecutive administration in either order, wherein preferably there is a time period while both (or all) active agents simultaneously exert their biological activities. The combinations of the invention may also be administered as a single pharmaceutical composition comprising the compound of formula (I) and the other therapeutic agent(s).

In a particular embodiment of therapy, the combination may be combined with surgical therapy and radiotherapy. The amounts of the combination and the relative timings of administration will be selected in order to achieve the desired combined therapeutic effect.

The compounds may be administered by any route appropriate to the condition to be treated. Suitable routes include oral, parenteral (including subcutaneous, intramuscular, intravenous, intraarterial, inhalation, intradermal, intrathecal, epidural, and infusion techniques), transdermal, rectal, nasal, topical (including buccal and sublingual), vaginal, intraperitoneal, intrapulmonary and intranasal. Topical administration can also involve the use of transdermal administration such as transdermal patches or iontophoresis devices. For local immunosuppressive treatment, the compounds may be administered by intralesional administration, including perfusing or otherwise contacting the graft with the inhibitor before transplantation.

It will be appreciated that the preferred route may vary with for example the condition of the recipient. Where the compound is administered orally, it may be formulated as a pill, capsule, tablet, etc. with a pharmaceutically acceptable carrier, glidant, or excipient. Where the compound is administered parenterally, it may be formulated with a pharmaceutically acceptable parenteral vehicle or diluent, and in a unit dosage injectable form, as detailed below.

The combinations as described herein may be employed for the treatment of a hyperproliferative disease or disorder, particularly hematological malignancies. As used herein, hematological malignancies relates to myeloid hematological malignancies and lymphoid hematological malignancies. As used herein, myeloid hematological malignancies and lymphoid hematological malignancies also include pre-malignant myeloid or lymphoid hematological disorders and non-neoplastic or non-malignant myeloproliferative or lymphoproliferative disorders.

In particular, the combinations of the present invention can be used for the treatment or prevention of:

-   -   Myeloid hematological malignancies, such as acute myeloid         leukemia (AML) (e.g. Erythroleukemia, acute megakaryoblastic         leukemia, Acute eosinophilic leukemia, Acute basophilic         leukemia, Acute myelomonocytic leukemia, acute myeloblastic         leukemia); Chronic myelogenous leukemia; Myelodysplasic         syndrome; Chronic myelomonocytic leukemia; and         Myeloproliferative diseases (e.g. myelofibrosis, acute         biphenotypic leukemia, Polycythemia vera, Chronic eosinophilic         leukemia/Hypereosinophilic syndrome, Essential thrombocytosis,         and Chronic eosinophilic leukemia/Hypereosinophilic syndrome)     -   Lymphoid Hematological malignancies, such as acute lymphoblastic         leukemia (ALL), T-cell lymphoblastic leukemia/lymphoma

In preferred embodiments, the combinations of the present invention are used for the treatment of myeloid hematological malignancies. In certain embodiments, the combinations of the invention are used for the treatment of acute myeloid leukemia. In certain embodiments, the combinations of the invention are preferentially used to treat myeloid or lymphoid hematological malignancies with translocation or rearrangements involving MLL, AF9, AF4, AF10, AML1, ETO, CALM; or mutation in NPM1 or Notch1, or LSD1 overexpression.

One particular embodiment of the invention relates to a method for the treatment of a hyperproliferative disorder, particularly a hematological malignancy, which method comprises sensitizing through administration of an LSD1 inhibitor followed by administering an effective amount of a combination as described herein to a human being or animal.

One particular embodiment of the invention relates to a method for the treatment of a hyperproliferative disorder, particularly a hematological malignancy, which method comprises sensitizing through administration of a compound of formula (I) or a pharmaceutically acceptable salt thereof followed by administering an effective amount of a combination as described herein to a human being or animal.

In another embodiment of the invention, an article of manufacture, or “kit”, containing a combination useful for the treatment of the diseases and disorders described above is provided.

In one embodiment, the article of manufacture comprises a container and a combination described herein.

One embodiment of the invention provides an article of manufacture comprising a combination as described herein useful in the treatment of a hyperproliferative disorder, particularly a hematological malignancy.

The kit may further comprise a label or package insert, on or associated with the container. The term “package insert” is used to refer to instructions customarily included in commercial packages of therapeutic products, that contain information about the indications, usage, dosage, administration, contraindications and/or warnings concerning the use of such therapeutic products. Suitable containers include, for example, bottles, vials, syringes, blister pack, etc. The container may be formed from a variety of materials such as glass or plastic. The container may hold a combination, or a formulation thereof, which is effective for treating the condition and may have a sterile access port (for example, the container may be an intravenous solution bag or a vial having a stopper pierceable by a hypodermic injection needle). The label or package insert indicates that the composition is used for treating the condition of choice, such as hyperproliferative disorders, particularly a hematological malignancy. In one embodiment, the label or package inserts indicates that the composition comprising the combination can be used to treat a disorder resulting from abnormal cell growth. The label or package insert may also indicate that the composition can be used to treat other disorders. Alternatively, or additionally, the article of manufacture may further comprise a second container comprising a pharmaceutically acceptable buffer, such as bacteriostatic water for injection (BWFI), phosphate-buffered saline, Ringer's solution and dextrose solution. It may further include other materials desirable from a commercial and user standpoint, including other buffers, diluents, filters, needles, and syringes.

The kit may further comprise directions for the administration of the combination, and, if present, the second pharmaceutical formulation. For example, if the kit comprises a first composition comprising a compound of formula (I), or a pharmaceutically acceptable salt thereof and a second pharmaceutical composition comprising one or more therapeutic agents selected from the group consisting of retinoic acid analogues, nucleoside analogues, DOT1L inhibitors, HDAC inhibitors, demethylating agents, FLT3 inhibitors, BCL2 inhibitors, MDM2 inhibitors, c-KIT inhibitors, BET inhibitors, anthracyclines, arsenic trioxide, hydroxyurea, and pharmaceutically acceptable salts thereof, the kit may further comprise directions for the simultaneous, sequential or separate administration of the first and second pharmaceutical compositions to a patient in need thereof.

In another embodiment, the kits are suitable for the delivery of solid oral forms of a combination, such as tablets or capsules. Such a kit preferably includes a number of unit dosages. Such kits can include a card having the dosages oriented in the order of their intended use. An example of such a kit is a “blister pack”. Blister packs are well known in the packaging industry and are widely used for packaging pharmaceutical unit dosage forms. If desired, a memory aid can be provided, for example in the form of numbers, letters, or other markings or with a calendar insert, designating the days in the treatment schedule in which the dosages can be administered.

According to one embodiment, a kit may comprise (a) a first container with a compound of formula (I), or a pharmaceutically acceptable salt thereof contained therein; (b) a second container with one therapeutic agents selected from the group consisting of retinoic acid analogues, nucleoside analogues, DOT1L inhibitors, HDAC inhibitors, demethylating agents, FLT3 inhibitors, BCL2 inhibitors, MDM2 inhibitors, c-KIT inhibitors, BET inhibitors, anthracyclines, arsenic trioxide, hydroxyurea, and pharmaceutically acceptable salts thereof and (c) a third container with a third pharmaceutical composition contained therein, wherein the third pharmaceutical formulation comprises another compound with anti-hyperproliferative activity selected from the group consisting of retinoic acid analogues, nucleoside analogues, DOT1L inhibitors, HDAC inhibitors, demethylating agents, FLT3 inhibitors, BCL2 inhibitors, MDM2 inhibitors, c-KIT inhibitors, BET inhibitors, anthracyclines, arsenic trioxide, hydroxyurea, and pharmaceutically acceptable salts thereof. Alternatively, or additionally, the kit may comprise another container comprising a pharmaceutically-acceptable buffer, such as bacteriostatic water for injection (BWFI), phosphate-buffered saline, Ringer's solution and dextrose solution. It may further include other materials desirable from a commercial and user standpoint, including other buffers, diluents, filters, needles, and syringes.

Where the kit comprises a composition of a compound of formula (I), or a pharmaceutically acceptable salt thereof and one or more therapeutic agents selected from the group consisting of retinoic acid analogues, nucleoside analogues, DOT1L inhibitors, HDAC inhibitors, demethylating agents, FLT3 inhibitors, BCL2 inhibitors, MDM2 inhibitors, c-KIT inhibitors, BET inhibitors, anthracyclines, arsenic trioxide, hydroxyurea, and pharmaceutically acceptable salts thereof, the kit may comprise a container for containing the separate compositions such as a divided bottle or a divided foil packet, however, the separate compositions may also be contained within a single, undivided container. Typically, the kit comprises directions for the administration of the separate components. The kit form is particularly advantageous when the separate components are preferably administered in different dosage forms (e.g., oral and parenteral), are administered at different dosage intervals, or when titration of the individual components of the combination is desired by the prescribing physician.

EXAMPLES

The following examples are provided for illustration of the invention. They should not be considered as limiting the scope of the invention, but merely as being representative thereof.

Example 1: Matrix Assays for Determination of Synergy Between ORY-1001 and Other Therapeutic Agents in Acute Myeloid Leukemia Cell Lines

The objective of this example is to determine synergism existing between ORY-1001 and other therapeutic agents. Table 1 summarizes the compounds tested in the combination therapy and cell the lines used.

TABLE 1 List of compounds that will be tested in combination with ORY-1001. Compound Class Cell lines ATRA RA analogue MV(4; 11), MOLM-13 ARAC Nucleotide analogue MV(4; 11), MOLM-13, OCI-AML3 EPZ5676 DOT1L inhibitor MV(4; 11), MOLM-13 SAHA HDAC inhibitor MV(4; 11), MOLM-13 Rocilinostat* HDAC inhibitor MV(4; 11), MOLM-13, OCI-AML3 Azacitidine Demethylating agent MV(4; 11), MOLM-13 Decitabine Demethylating agent MV(4; 11), MOLM-13 Quizartinib FLT3 inhibitor MV(4; 11), MOLM-13 ABT737 BCL2 inhibitor MV(4; 11), MOLM-13 Nutlin3A MDM2 inhibitor MOLM-13 *Also known as Ricolinostat and ACY-1215.

1.1 Experimental Design

1.1.1 Cell Lines and Culture Conditions

AML cell lines were maintained in RPMI 10% FBS medium at 37° C. in a humidified incubator with controlled 5% CO₂ atmosphere. Cell freezing and thawing was performed following recommendation from ATCC. Genetic profiling of the cell lines used is available in table 2.

TABLE 2 Genetic characterization of the AML cell lines reported in this document. Cell lines Tissue of origin Mutational status THP1 Acute monocytic leukaemia (M5b) MLL-AF9 rearraged MV4-11 Acute monocytic leukaemia (M5b) MLL-AF4 rearranged, FLT3-ITD OCI-AML3 Acute myelomonocitic leukaemia (M4) MLL wt, NPM1 mut, DNMT3a mut OCI-AML2 Acute myelomonocitic leukaemia (M4) MLL wt, NPM1 wt, DNMT3a mut MOLM13 Acute monoblastic leukaemia (M5a) MLL-AF9, FLT3-ITD HL60 Acute promyelocytic leukaemia MLL wt, Myc amplification KASUMI1 Acute myeloid leukaemia MLL wt, AML-ETO rearranged

1.1.2 Viability Assays (96 Hours)

Cells were seeded at the optimal density (to guarantee linear growth during the treatment), as previously determined (4000 cells/well, except 16000 cells/well in the case of KASUMI-1 cells), in 96-well plates with 50 μL of medium. Three wells were reserved for each experimental condition; medium-only and vehicle-treated controls were also added for background correction and normalization respectively. After seeding, 50 μL of medium containing 8 serial dilutions (1:3) of ORY-1001 (or any other candidates for combinatorial treatment) were added to the cells. Cells were then incubated for 96 hours at 37° C. in a controlled 5% CO₂ atmosphere, prior to evaluate cell viability using Alamar Blue® (ThermoFisher Scientific, Waltham, Mass./USA) viability staining. Alamar Blue® is a cell viability indicator that uses the natural reducing power of living cells to convert resazurin to the fluorescent molecule, resorufin⁴³. Briefly, Alamar Blue stock solution was diluted 1:20 in the culture medium and, after 3 hours incubation, fluorescence was detected using a TECAN Infinity 2000 plate reader (Tecan Group Ltd., Männedorf, C H; 540-570 nm excitation wavelength, 580-610 nm emission wavelength). For each condition, the average fluorescence was calculated from 3 technical replicates; background correction was calculated from the fluorescence of medium-only controls. Data were analyzed using the GraphPad PRISM® version 5.01 (GraphPad Software, Inc., La Jolla, Calif./USA) to calculate the best-fitting curve and the EC₅₀ value.

1.1.3 9×9 Matrix Viability Assays

Each matrix assay was distributed across 2 plates following the scheme illustrated below in FIG. 1.

Cells were seeded at the optimal density (4000 cells/wells, as previously determined) in 96-well plates with 50 μL of medium; the wells at edges of the plates were left with 100 μL of medium without cells, for background correction. Each of the two compounds was added in 25 μL, resulting in a final volume of 100 μL of medium. As shown in FIG. 1, the matrix was designed with increasing concentrations of ORY-1001 from left to right and increasing concentrations of the compound of interest (see table 1) from top to the bottom. The first and the last row of plate #1 have been repeated in plate #2 (indicated by red arrows in FIG. 1), to confirm reproducibility across the two plates. The concentrations tested for both the compounds were covering a 256-folds range obtained through 8 1:2 dilutions steps, designed to have the EC₅₀s of both the compounds centered horizontally and vertically on the matrix (the EC₅₀s of ORY-1001 and the other compound correspond to the 5th well from the right and from the bottom, as indicated in FIG. 1). The EC₅₀ values for the compounds tested in the matrix assays were previously obtained through single agent assays performed as detailed in the section 1.1.2. For compounds in which a wide concentration range was tested (Decitabine, Azacitidine and Nutlin3A) serial dilutions were performed in 1:3 steps.

Viability was then determined using Alamar Blue staining as detailed in the section 1.1.2.

1.1.3.1 9×9 Matrix Viability Assays (Data Analysis)

For each matrix assay, data were then normalized against the vehicle-treated controls (<0.4% DMSO, in the upper left corner) to obtain the percentage value of relative viability, according to the following formula:

% relative viability=RFU treated cells/RFU vehicle control×100

The values of percentage viability were then analyzed using GraphPad PRISM® version 5.01 (GraphPad Software, Inc., La Jolla, Calif./USA) to calculate the best-fitting curve and the EC₅₀ values.

At this point the Fraction affected (Fa) was calculated using the formula

Fa=1−(% relative viability/100)

for the following conditions:

-   -   Cells treated with serial dilutions of ORY-1001 as single agent         (average of the first row of the first and second plate of each         matrix assay)     -   Cells treated with serial dilutions of the compound of interest         as single agent (in the first column of the matrix assay)     -   Cell treated with ORY-1001 and the compound of interest at a         fixed ratio corresponding to the ratio of EC₅₀ values (values of         % relative viability in the diagonal of the matrix assay;         highlighted in FIG. 1).

The Fa values previously described were then averaged across the two technical duplicates, before analysis with Calcusyn.

The Calcusyn software (http://www.biosoft.com/w/calcusyn.htm, Biosoft, Cambridge, UK) is designed to determine the nature (synergistic, additive or antagonistic) of the interaction between two compounds, on the basis of the Median Effect Principle and the Combination Index Theorem⁴⁴. In order to generate informative results, the data that are going to be processed with Calcusyn (both for the single agents and the drug combination) need to fit with these theoretical models. For this reason, it is crucial to remove possible outliers and data points characterized by poor fit to the Median Effect Principle⁴⁵. In order to achieve this, the following strategy was adopted for data filtering.

In the first step data dispersion was reduced removing points characterized by:

1) Fa<0.1

2) Increase in Fa<0.03, compared to the previous point (if Fa>0.9).

These conditions define the plateaus of the dose response curve, in which cells have been treated with very low or very high concentrations of compounds (or combos), resulting in reduction of viability close to 0% or 100% (equivalent to Fa value close to 0 or 1 respectively). To be noted that in these areas of the dose-response curve the changes in Alamar Blue signal are very small and most likely the result of random noise with very little biological significance.

Next, for each data point, Log₁₀(Concentration) and Log₁₀(Fa/(1−Fa)) were calculated and a dot plot graph was generated reporting the former value on the x axis and the latter on the y axis. With Excel, a regression line was then obtained (corresponding to the Median Effect Equation).

At this point the distance from the regression line was calculated for each data point with the equation:

Distance(ax+by+c=0;X,Y)=(aX+bY+c)/<√(a ² +b ²)

Outliers are identified on the basis of their distance from the Median Effect Equation, using the Grubbs test. For each data point, the Grubbs test was performed on the absolute value of the distance, according to the following formula (to be noted that the variable for the Grubbs test can be called interchangeably G or Z):

G=(X _(n) −X _(average))/s

Where X_(n) stands for the absolute value of the distance of each points from the regression line; X_(average) stands for average of all the X_(n) values and s stands for the standard deviation. Values of G above G_(crit) (calculated for α=0.2 as shown below) identify outliers not fitting on the Median Effect Equation. Such data points have been removed to successfully calculate the Combination Index with Calcusyn.

$G_{crit} = \frac{\left( {n - 1} \right)t_{crit}}{\sqrt{n\left( {n - 2 + t_{crit}^{2}} \right)}}$

When possible, the test was reiterated more than once to remove multiple outliers, until:

-   -   1. no further outliers were identified or     -   2. R²>0.95. To measure data quality, the R value is calculated         also by the Calcusyn software (good data are characterized by R         value above 0.95⁴⁶.

1.1.3.2 Calcusyn Output

On the x axis is reported the Fractional Effect (also called Fraction Affected referred in the text as Fa), representing the fraction of cells affected by the treatment (in the case of a cytotoxic treatment the Fractional Effect corresponds to viability reduction compared to vehicle controls, where 1 is equal to 100%). On the y axis is reported the combination index, which can be either synergistic (CI<1), additive (CI=1) or antagonistic (CI>1). The crosses stand for the experimental data points, the central line is the CI curve, the upper and the lower lines define the range of 1.96 standard deviations (SD) above and below the CI.

1.1.4 Combinatorial Treatments Dasatinib/ORY-1001 and JQ1/ORY-1001

Cells were seeded at the density of 2500 cells/well in 96-well plates with 50 μL of medium; the wells at edges of the plates were left with 100 μL of medium without cells, for background correction. Each of the two compounds was added in 25 μL, resulting in a final volume of 100 μL of medium. Cells were treated with serial 1:3 dilution of both ORY-1001 and either Dasatinib or JQ-1. The ratio ORY-1001/Dasatinib and ORY-1001/JQ1 was respectively 1:1000 and 1:200.

Viability was then determined using Alamar Blue staining as detailed in the section 1.1.2.

1.1.4.1 Combinatorial Treatments Dasatinib/ORY-1001 and JQ1/ORY-1001 (Data Analysis)

Data analysis was performed as described in the section 1.1.3.1.

1.1.4.2 Calcusyn Output

Output of the Calcusyn software as described in the section 1.1.3.2.

1.1.5 Combinatorial Treatment ORY-1001/Hydroxvurea

Cells were seeded at the density of 4000 cells/well in 96-well plates with 50 μL of medium; the wells at edges of the plates were left with 100 μL of medium without cells, for background correction. Each of the two compounds was added in 25 μL, resulting in a final volume of 100 μL of medium. Cells were treated with serial 1:3 dilution of Hydroxyurea in presence of a fixed concentration of either ORY-1001 (5 nM) or vehicle (0.05%).

Viability was then determined using Alamar Blue staining as detailed in the section 1.1.2. Data were analyzed using the GraphPad PRISM® version 5.01 (GraphPad Software, Inc., La Jolla, Calif./USA) to calculate the best-fitting curve and the EC₅₀ value.

1.1.6 Combinatorial Treatment ORY-1001/As₂O₃

Cells were seeded at the density of 2500 cells/well in 96-well plates with 50 μL of medium; the wells at edges of the plates were left with 100 μL of medium without cells, for background correction. Each of the two compounds was added in 25 μL, resulting in a final volume of 100 μL of medium. Cells were treated with serial 1:3 dilution of As0₃ in presence of a fixed concentration of either ORY-1001 (5 nM) or vehicle (0.05%).

Viability was then determined using Alamar Blue staining as detailed in the section 1.1.2. Data were analyzed using the GraphPad PRISM® version 5.01 (GraphPad Software, Inc., La Jolla, Calif./USA) to calculate the best-fitting curve and the EC₅₀ value.

1.2 Results

1.2.1 ORY-1001 Single Agent

After determining the optimal growth conditions for the THP-1, MV(4;11), HL-60, OCI-AML3, KASUMI-1, OCI-AML2 and MOLM-13 AML cell lines, incubations were performed with either vehicle (DMSO 0.05%) or serial 1:3 dilution of ORY-1001 (range from 0.015 to 100 nM) as described in the section 1.1.2. With the exception of OCI-AML2, in the AML cell lines tested, ORY-1001 induced a reduction of viability greater than 20% (compared to vehicle controls), with EC₅₀ values in the sub-nanomolar range.

1.2.2 ATRA Single Agent

After determining the optimal growth conditions for the THP-1, MV(4;11), HL-60, OCI-AML3, KASUMI-1, OCI-AML2 and MOLM-13 AML cell lines, incubations were performed with either vehicle (DMSO 0.05%) or serial 1:3 dilution of ATRA (range from 0.015 to 100 nM) as described in the section 1.1.2. Reduction of viability greater than 20% (compared to vehicle controls) was detected in the THP-1 (EC₅₀=1.7 nM), MV(4;11) (EC₅₀=2.8 nM), HL-60 (EC₅₀=2.7 nM), OCI-AML2 (EC₅₀=5.9 nM), OCI-AML3 (EC₅₀=0.8 nM) and MOLM-13 cells (EC₅₀=4.8 nM).

1.2.2.1 Combination ORY-1001/ATRA

Matrix treatments with ATRA (0.16-40 nM) and ORY-1001 (0.006-1.6 nM) were performed on MV(4;11) and MOLM-13 cells as described in the section 1.1.3. Data analysis and calculation of combination indexes as reported in 1.1.3.1. The results obtained are shown in FIGS. 2A and 2B.

In the conditions tested, synergy (CI<1) was detected between ORY-1001 and ATRA at Fa value above 0.5 in MV(4;11) cells (n=2) and 0.8 in MOLM-13 cells (n=2).

1.2.3 ARA-C Single Agent

After determining the optimal growth conditions for the THP-1, MV(4;11), HL-60, OCI-AML3, KASUMI-1, OCI-AML2 and MOLM-13 AML cell lines, incubations were performed with either vehicle (DMSO 0.05%) or serial 1:3 dilution of ARA-C (range from 0.15 to 1000 nM) as described in the section 1.1.2. Reduction of viability greater than 20% (compared to vehicle controls) was detected in the THP-1 (EC50=251.7 nM), MV(4;11) (EC50=198 nM), HL-60 (EC50=43.5 nM), OCI-AML2 (EC50=26.5 nM), OCI-AML3 (EC50=144.8 nM), KASUMI-1 (EC50=28.7 nM) and MOLM-13 cells (EC50=78.5 nM).

1.2.3.1 Combination ORY-1001/ARA-C

Matrix treatments with ARA-C (6.25-1600 nM) and ORY-1001 (0.006-1.6 nM) were performed on MV(4-11), OCI-AML3 and MOLM-13 cells as described in the section 1.1.3. Data analysis and calculation of combination indexes as reported in 1.1.3.1. The results obtained are shown in FIGS. 3A, 3B and 3C.

In the conditions tested, ORY-1001 synergistically enhances the response of MV(4;11) cells to ARA-C for Fa>0.5 (n=1). In OCI-AML3 and MOLM-13 cells synergy between ARA-C and ORY-1001 was detected at Fa>0.7 and Fa>0.6 respectively (n=2).

1.2.4 EPZ5676 Single Agent

After determining the optimal growth conditions for the THP-1, MV(4;11), HL-60, OCI-AML3, KASUMI-1, OCI-AML2 and MOLM-13 AML cell lines, incubations were performed with either vehicle (DMSO 0.05%) or serial 1:3 dilution of EPZ5676 (range from 1.5 nM to 10 μM) as described in the section 1.1.2. Reduction of viability greater than 20% (compared to vehicle controls) was detected in MV(4;11) (EC₅₀=16 nM) and MOLM-13 cells (EC₅₀=44.7 nM).

1.2.4.1 Combination ORY-1001/EPZ5676

Matrix treatments with EPZ5676 (1.25-320 nM) and ORY-1001 (0.006-1.6 nM) were performed on MV(4;11) and MOLM-13 cells as described in the section 1.1.3. Data analysis and calculation of combination indexes as reported in 1.1.3.1. The results obtained are shown in FIGS. 4A and 4B.

In the conditions tested, synergy between ORY-1001 and EPZ56756 was detected at Fa>0.4 in MV(4;11) cells (n=2) and at Fa>0.3 in MOLM-13 cells (n=2).

1.2.5 EPZ004777 Single Agent

After determining the optimal growth conditions for the THP-1, MV(4;11), HL-60, OCI-AML3, KASUMI-1, OCI-AML2 and MOLM-13 AML cell lines, incubations were performed with either vehicle (DMSO 0.2%) or serial 1:3 dilution of EPZ004777 (range from 2.5 nM to 16.7 μM) as described in the section 1.1.2. Reduction of viability greater than 20% (compared to vehicle controls) was detected in MV(4;11) (EC₅₀=118 nM) and MOLM-13 cells (EC₅₀=108.3 nM).

1.2.6 SAHA Single Agent

After determining the optimal growth conditions for the THP-1, MV(4;11), HL-60, OCI-AML3, KASUMI-1, OCI-AML2 and MOLM-13 AML cell lines, incubations were performed with either vehicle (DMSO 0.05%) or serial 1:3 dilution of SAHA (range from 1.5 nM to 10 μM) as described in the section 1.1.2. Reduction of viability greater than 20% (compared to vehicle controls) was detected in the THP-1, MV(4;11), HL-60, OCI-AML2, OCI-AML3, KASUMI-1 and MOLM-13 cells (EC₅₀ in the 100-1000 nM range).

1.2.6.1 Combination ORY-1001/SAHA

Matrix treatments with SAHA (6.25-1600 nM) and ORY-1001 (0.006-1.6 nM) were performed on MV(4;11) and MOLM-13 cells as described in the section 1.1.3. Data analysis and calculation of combination indexes as reported in 1.1.3.1. The results obtained are shown in FIGS. 5A and 5B.

In the conditions tested, synergistic interaction between ORY-1001 and SAHA was detected in MV(4;11) at Fa values between 0.3 and 0.8 (n=2) and in MOLM-13 cells at Fa>0.4 (n=1).

1.2.7 Rocilinostat Single Agent

After determining the optimal growth conditions for the THP-1, MV(4;11), HL-60, OCI-AML3, KASUMI-1, OCI-AML2 and MOLM-13 AML cell lines, incubations were performed with either vehicle (DMSO 0.05%) or serial 1:3 dilution of Rocilinostat (range from 1.5 nM to 10 μM) as described in the section 1.1.2. Reduction of viability greater than 20% (compared to vehicle controls) was detected in the THP-1, MV(4;11), HL-60, OCI-AML2, OCI-AML3, KASUMI-1 and MOLM-13 cells (EC₅₀ in the 0.5-3 μM range).

1.2.7.1 Combination ORY-1001/Rocilinostat

Matrix treatments with Rocilinostat (15.6-4000 nM) and ORY-1001 (0.006-1.6 nM) were performed on MV(4;11), OCI-AML3 and MOLM-13 cells as described in the section 1.1.3. Data analysis and calculation of combination indexes as reported in 1.1.3.1. The results obtained are shown in FIGS. 6A, 6B and 6C.

In the conditions tested, ORY-1001 interacts synergistically with Rocilinostat at Fa>0.6 in MV(4;11) cells (n=2) and Fa>0.4 in OCI-AML3 cells (n=2). In MOLM-13 cells synergy was detected for Fa>0.8 (n=2).

1.2.8 Entinostat Single Agent

After determining the optimal growth conditions for the THP-1, MV(4;11), HL-60, OCI-AML3, KASUMI-1, OCI-AML2 and MOLM-13 AML cell lines, incubations were performed with either vehicle (DMSO 0.1%) or serial 1:3 dilution of Entinostat (range from 7.6 nM to 50 μM) as described in the section 1.1.2. Reduction of viability greater than 20% (compared to vehicle controls) was detected in the THP-1 (EC₅₀=230 nM), MV(4;11) (EC₅₀=98.5 nM), HL-60 (EC₅₀=42 nM), OCI-AML2 (EC₅₀=106.5 nM), OCI-AML3 (EC₅₀=55.2 nM), KASUMI-1 (EC₅₀=167.5 nM) and MOLM-13 cells (EC₅₀=52 nM).

1.2.9 Azacitidine Single Agent

After determining the optimal growth conditions for the THP-1, MV(4;11), HL-60, OCI-AML3, KASUMI-1, OCI-AML2 and MOLM-13 AML cell lines, incubations were performed with either vehicle (DMSO 0.05%) or serial 1:3 dilution of Azacitidine (range from 15 nM to 100 μM) as described in the section 1.1.2. Reduction of viability greater than 20% (compared to vehicle controls) was detected in the THP-1 (EC₅₀=2881.5 nM), MV(4;11) (EC₅₀=1112 nM), HL-60 (EC₅₀=1812 nM), OCI-AML2 (EC₅₀=1851.7 nM), OCI-AML3 (EC₅₀=889.4 nM), KASUMI-1 (EC₅₀=2281.7 nM) and MOLM-13 cells (EC₅₀=322.8 nM).

1.2.9.1 Combination ORY-1001/Azacitidine

Matrix treatments with Azacitidine (9.5 nM-62.3 μM) and ORY-1001 (0.001-8 nM) were performed on MV(4;11) and MOLM-13 cells as described in the section 1.1.3. Data analysis and calculation of combination indexes as reported in 1.1.3.1. The results obtained are shown in FIGS. 7A and 7B.

In the conditions tested, in both MV(4;11) and MOLM-13 cells ORY-1001 synergizes with Azacitidine at Fa>0.3 (n=2).

1.2.10 Decitabine Single Agent

After determining the optimal growth conditions for the THP-1, MV(4;11), HL-60, OCI-AML3, KASUMI-1, OCI-AML2 and MOLM-13 AML cell lines, incubations were performed with either vehicle (DMSO 0.05%) or serial 1:3 dilution of Decitabine (range from 1.5 nM to 10 μM) as described in the section 1.1.2. Reduction of viability greater than 20% (compared to vehicle controls) was detected in the THP-1 (EC₅₀=95 nM), MV(4;11) (EC₅₀=79.5 nM), HL-60 (EC₅₀=42.1 nM), OCI-AML2 (EC₅₀=36 nM), OCI-AML3 (EC₅₀=100.5 nM), KASUMI-1 (EC₅₀=24 nM) and MOLM-13 cells (EC₅₀=12.6 nM).

1.2.10.1 Combination ORY-1001/Decitabine

Matrix treatments with Decitabine (0.4-2430 nM) and ORY-1001 (0.004-24.3 nM) were performed on MV(4;11) and MOLM-13 cells as described in the section 1.1.3. Data analysis and calculation of combination indexes as reported in 1.1.3.1. The results obtained are shown in FIGS. 8A and 8B.

In the conditions tested, synergistic effect between ORY-1001 and Decitabine was detected for Fa>0.5 (n=2) in both MV(4;11) and MOLM-13 cells.

1.2.11 Quizartinib Single Agent

After determining the optimal growth conditions for the THP-1, MV(4;11), HL-60, OCI-AML3, KASUMI-1, OCI-AML2 and MOLM-13 AML cell lines, incubations were performed with either vehicle (DMSO 0.1%) or serial 1:3 dilution of Quizartinib (range from 2.3 nM to 15 μM) as described in the section 1.1.2. Due to increased sensitivity, the range was adjusted for MV(4;11) (0.0015-10 nM) and MOLM-13 cells (0.01-60 nM). Reduction of viability greater than 20% (compared to vehicle controls) was detected in the MV(4;11) (EC₅₀<1 nM), OCI-AML2 (EC₅₀=830 nM) and MOLM-13 cells (EC₅₀<1 nM).

1.2.11.1 Combination ORY-1001/Quizartinib

Matrix treatments with Quizartinib (0.031-8 nM) and ORY-1001 (0.006-1.6 nM) were performed on MV(4;11) and MOLM-13 cells as described in the section 1.1.3. Data analysis and calculation of combination indexes as reported in 1.1.3.1. The results obtained are shown in FIGS. 9A and 9B.

In the conditions tested, in MV(4;11) and MOLM-13 cells (both harboring the FLT3-ITD mutation), the combination index for ORY-1001/Quizartinib combo is below 1 (synergistic interaction) at Fa>0.2 (n=2).

1.2.12 ABT737 Single Agent

After determining the optimal growth conditions for the THP-1, MV(4;11), HL-60, OCI-AML3, KASUMI-1, OCI-AML2 and MOLM-13 AML cell lines, incubations were performed with either vehicle (DMSO 0.05%) or serial 1:3 dilution of ABT737 (range from 0.15 nM to 1 μM) as described in the section 1.1.2. Reduction of viability greater than 20% (compared to vehicle controls) was detected in the MV(4;11) (EC₅₀=6.3 nM), HL-60 (EC₅₀=113.4 nM), OCI-AML2 (EC₅₀=14 nM), KASUMI-1 (EC₅₀=124 nM) and MOLM-13 cells (EC₅₀=25 nM).

1.2.12.1 Combination ORY-1001/ABT737

Matrix treatments with ABT373 (0.3-80 nM) and ORY-1001 (0.006-1.6 nM) were performed on MV(4;11) and MOLM-13 cells as described in the section 1.1.3. Data analysis and calculation of combination indexes as reported in 1.1.3.1. The results obtained are shown in FIGS. 10A and 10B.

Synergy between ORY-1001 and ABT737 was detected at Fa>0.7 and Fa>0.9 respectively in MV(4;11) (n=2) and MOLM-13 cells (n=11).

1.2.13 Nutlin3A Single Agent

After determining the optimal growth conditions for the THP-1, MV(4;11), HL-60, OCI-AML3, KASUMI-1, OCI-AML2 and MOLM-13 AML cell lines, incubations were performed with either vehicle (DMSO 0.2%) or serial 1:3 dilution of Nutlin3A (range from 0.6 nM to 4 μM) as described in the section 1.1.2. Reduction of viability greater than 20% (compared to vehicle controls) was detected in the THP-1 (EC₅₀=323.7 nM), OCI-AML2 (EC₅₀=446.5 nM), OCI-AML3 (EC₅₀=659 nM) and MOLM-13 cells (EC₅₀=127.7 nM).

1.2.13.1 Combination ORY-1001/Nutlin3A

Matrix treatments with Nutlin3A (1.1-7290 nM) and ORY-1001 (0.001-8.1 nM) were performed on MOLM-13 cells as described in the section 1.1.3. Data analysis and calculation of combination indexes as reported in 1.1.3.1. The results obtained are shown in FIG. 11.

In the conditions tested, in MOLM-13 cells, ORY-1001 displays synergistic interaction with Nutlin3A for Fa values above 0.8 (n=2).

1.2.14 Combination ORY-1001/Dasatinib

Treatment with a combination of Dasatinib (6 nM-40 μM) and ORY-1001 (0.006-40 nM) were performed on MV(4;11) cells as described in the section 1.1.4. Data analysis and calculation of combination indexes as reported in 1.1.4.1. The results obtained are shown in FIG. 12.

In the conditions tested, in MV(4;11) cells, ORY-1001 displays synergistic interaction with Dasatinib for Fa values between 0.4 and 0.9 (n=11).

1.2.15 Combination ORY-1001/JQ1

Treatment with a combination of JQ1 (0.9 nM-6000 nM) and ORY-1001 (0.004-30 nM) were performed on MV(4;11) cells as described in the section 1.1.4. Data analysis and calculation of combination indexes as reported in 1.1.4.1. The results obtained are shown in FIG. 13.

In the conditions tested, in MV(4;11) cells, ORY-1001 displays synergistic interaction with JQ1 for Fa values between 0.6 and 0.9 (n=3).

1.2.16 Combination ORY-1001/Hydroxvurea

Treatment with serial dilution of Hydroxyurea (0.076-500 nM) was performed in presence of either ORY-1001 (5 nM) or vehicle (DMSO 0.05%) in MV(4;11) cells, as described in the section 1.1.5. The results obtained are shown in FIG. 14.

In the conditions tested, ORY-1001 potentiates the response of MV(4;11) cells to Hydroxyurea (n=1).

1.2.17 Combination ORY-1001/As₂O₃

Treatment with serial dilution of As₂O₃ (0.039-10 nM) was performed in presence of either ORY-1001 (5 nM) or vehicle (DMSO 0.05%) in MV(4;11) cells, as described in the section 1.1.6. The results obtained are shown in FIG. 15.

In the conditions tested, ORY-1001 potentiates the response of MV(4;11) cells to As₂O₃ (n=1).

Example 2: Matrix Assays for Determination of Synergy Between ORY-1001 and Other Compounds of Interest in MOLT4 Cells (Acute Lymphoid Leukemia)

The objective of this example is to determine synergism existing between ORY-1001 and other therapeutic agents in MOLT4 cells. Table 3 summarizes the compounds tested in the combination therapy and the cell line used.

TABLE 3 List of compounds that will be tested in combination with ORY-1001. Compound Class Cell lines ARAC Nucleotide analogue MOLT-4 SAHA HDAC inhibitor MOLT-4 Rocilinostat* HDAC inhibitor MOLT-4 Entinostat HDAC inhibitor MOLT-4 Azacitidine Demethylating agent MOLT-4 Decitabine Demethylating agent MOLT-4 ABT737 BCL2 inhibitor MOLT-4 *Also known as Ricolinostat and ACY-1215.

2.1 Experimental Design

2.1.1 Cell Lines and Culture Conditions

MOLT4 cells were maintained in RPMI 10% FBS medium at 37° C. in a humidified incubator with controlled 5% CO₂ atmosphere. Cell freezing and thawing was performed following recommendation from ATCC. Genetic profiling of the cell lines used is available in table 4.

TABLE 4 Genetic characterization of the ALL cell line reported in this document. Cell lines Tissue of origin Mutational status MOLT4 Acute lymphoblastic T-cell leukaemia MLL wt

2.1.2 Viability Assays (10 Days)

The effects of ORY-1001 on viability of MOLT-4 cells were evaluated after 10 days of treatment, as a shorter treatment (96 hours) is not affecting the viability of this cell line (data not shown).

MOLT4 cells were seeded at the optimal density, as previously determined (5000 cells/well), in 96-well plates with 50 μL of medium. Three wells were reserved for each experimental condition; medium-only and vehicle-treated controls were also added for background correction and normalization respectively. After seeding, 50 μL of medium containing 8 1:3 serial dilution of ORY-1001 were added to the cells (range 0.015-100 nM). Cells were then incubated for 6 days at 37° C. in a controlled 5% CO2 atmosphere. On the sixth day, 100 μL of medium with serial dilutions of ORY-1001 (as described previously) or vehicle were added to the cells. Medium without compound (100μ) was added to background control.

After 4 additional days of incubation, cell viability was evaluated using the Alamar Blue® staining as detailed in the section 1.1.2.

2.1.3 9×9 Matrix Viability Assays with 100 nM ORY-1001 Pre-Treatment

Each matrix assay was distributed across 2 plates as described in 1.1.3. Matrix assay was adapted according to the observation reported in the section above (2.1.2).

MOLT4 cells were seeded at the optimal density (5000 cells/wells, as previously determined) in 96-well plates with 50 μL of medium. The edges of the plate were filled with 100 μL of medium only, for background correction. For the initial pre-treatment with ORY-1001, 50 μL of medium were added to the cells, resulting in a final volume of 100 μL of medium. Pretreatment of 6 days was performed with a range of ORY-1001 concentrations, obtained through 8 1:2 dilutions steps, designed to have the EC₅₀ values for ORY-1001 centered vertically on the matrix. For compounds in which a wider concentration range was tested (Decitabine and Azacitidine) serial dilutions were performed in 1:3 steps. Cells were then incubated for 6 days in a 5% CO₂ controlled atmosphere.

On the sixth day, additional 100 μL of medium containing serial dilution of both ORY-1001 and the compound of interest were added to each well (200 μL final volume). As described before, for background correction, 100 μL of medium without cells were also added to the edges of the plate (200 μL final volume). As shown in FIG. 1, the matrix was designed with increasing concentrations of ORY-1001 from left to right and increasing concentrations of the compound of interest from top to the bottom. The first and the last row of plate #1 have been repeated in plate #2 (indicated by red arrows in FIG. 1) to verify reproducibility across the two plates. The concentrations tested for both the compounds were covering a 256-folds range obtained through 8 1:2 dilutions steps, designed to have the EC₅₀s of both the compounds centered horizontally and vertically on the matrix (the EC₅₀s of ORY-1001 and the other compound correspond to the 5th well from the right and from the bottom, as indicated in FIG. 1). For compounds in which a wide concentration range was tested (Decitabine and Azacitidine Nutlin3A) serial dilutions were performed in 1:3 steps. At this point, cells were incubated for further 96 hours with both the compound.

After 4 days of co-treatment with ORY-1001 and the compound of interest (day 10), Alamar Blue® stock solution was diluted 1:20 in the culture medium and, after 3 hours incubation, fluorescence was detected using a TECAN Infinity 2000 plate reader (Tecan Group Ltd., Männedorf, C H; 540-570 nm excitation wavelength, 580-610 nm emission wavelength). For each condition, background correction was calculated from the fluorescence of medium-only controls. Matrix assays were performed in technical duplicate.

2.1.3.1 9×9 Matrix Viability Assays with 100 nM ORY-1001 Pre-Treatment (Data Analysis)

Data analysis was performed as described in the section 1.1.3.1.

2.1.3.2 Calcusyn Output

Output of the Calcusyn software as described in the section 1.1.3.2.

2.2 Results

2.2.1 ORY-1001 Single Agent

After determining the optimal growth conditions for the MOLT4 cells, incubations were performed with either vehicle (DMSO 0.05%) or serial 1:3 dilution of ORY-1001 (range from 0.015 to 100 nM) as described in the section 2.1.2. In the conditions tested, viability reduction at the highest ORY-1001 concentration (100 nM) was greater than 20% (compared to vehicles), with EC₅₀ in the sub-nanomolar range.

2.2.2 Combination ORY-1001/ARA-C

Matrix treatment with ARA-C (6.25-1600 nM) and ORY-1001 (0.08-20 nM) was performed on MOLT-4 cells as described in the section 2.1.3. Data analysis and calculation of combination indexes as reported in 2.1.3.1. The results obtained are shown in FIG. 16.

In the conditions tested, In MOLT4 cells, ORY-1001 synergistically enhances the effects of ARAC for Fa values above 0.2 (n=2).

2.2.3 Combination ORY-1001/SAHA

Matrix treatment with SAHA (12.5-3200 nM) and ORY-1001 (0.08-20 nM) was performed on MOLT-4 cells as described in the section 2.1.3. Data analysis and calculation of combination indexes as reported in 2.1.3.1. The results obtained are shown in FIG. 17.

In the conditions tested, Synergistic interaction between ORY-1001 and SAHA was detected for Fa values comprised between 0.3 and 0.8 (n=2).

2.2.4 Combination ORY-1001/Rocilinostat

Matrix treatment with Rocilinostat (31.25-8000 nM) and ORY-1001 (0.08-20 nM) was performed on MOLT-4 cells as described in the section 2.1.3. Data analysis and calculation of combination indexes as reported in 2.1.3.1. The results obtained are shown in FIG. 18.

In the conditions tested, as previously observed for SAHA, synergy between ORY-1001 and Rocilinostat was detected for Fa values between 0.2 and 0.6 (n=1).

2.2.5 Combination ORY-1001/Entinostat

Matrix treatment with Entinostat (15.6-4000 nM) and ORY-1001 (0.08-20 nM) was performed on MOLT-4 cells as described in the section 2.1.3. Data analysis and calculation of combination indexes as reported in 2.1.3.1. The results obtained are shown in FIG. 19.

In the conditions tested, as previously observed for SAHA, synergy between ORY-1001 and Entinostat was detected for Fa values between 0.2 and 0.9 (n=2).

2.2.6 Combination ORY-1001/Azacitidine

Matrix treatment with Azacitidine (13.72 nM-90 μM) and ORY-1001 (0.012-81 nM) was performed on MOLT-4 cells as described in the section 2.1.3. Data analysis and calculation of combination indexes as reported in 2.1.3.1. The results obtained are shown in FIG. 20.

In the conditions tested, synergy between Azacitidine and ORY-1001 was detected only in the narrow range of Fa valued between 0.2 and 0.4 (n=2).

2.2.7 Combination ORY-1001/Decitabine

Matrix treatment with Decitabine (1.5 nM-10 μM) and ORY-1001 (0.012-81 nM) was performed on MOLT-4 cells as described in the section 2.1.3. Data analysis and calculation of combination indexes as reported in 2.1.3.1. The results obtained are shown in FIG. 21.

In the conditions tested, Decitabine strongly synergizes with ORY-1001 within a wide range of Fa values (Fa values between 0.1 and 0.9; n=1).

2.2.8 Combination ORY-1001/ABT737

Matrix treatment with ABT737 (19.53-5000 nM) and ORY-1001 (0.08-20 nM) was performed on MOLT-4 cells as described in the section 2.1.3. Data analysis and calculation of combination indexes as reported in 2.1.3.1. The results obtained are shown in FIG. 22.

In the conditions tested, in MOLT4 cells, synergy between ORY-1001 and ABT737 was detected for Fa values greater than 0.6 (n=2).

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1. A combination comprising a compound of formula (I):

or a pharmaceutically acceptable salt thereof, and one or more therapeutic agents selected from a retinoic acid analogue, a nucleoside analogue, a DOT1L inhibitor, a HDAC inhibitor, a demethylating agent, an FLT3 inhibitor, a BCL2 inhibitor, an MDM2 inhibitor, a c-KIT inhibitor, a BET inhibitor, an anthracycline, arsenic trioxide, hydroxyurea and pharmaceutically acceptable salts thereof.
 2. The combination according to claim 1 comprising a compound of formula (I):

or a pharmaceutically acceptable salt thereof, and one or more therapeutic agents selected from tretinoin, cytarabine, sapacitabine, clofarabine, elacytarabine, fludarabine, cytarabine ocfosfate, gemcitabine, 2-chloro-2-deoxyadenosine (also known as 2-CDA), troxacitabine, forodesine, nelarabine, pinometostat, EPZ-004777, SGC-0946, Belinostat, Panobinostat, Vorinostat, Ricolinostat, Entinostat, Mocetinostat, Abexinostat, Resminostat, Givinostat, Quisinostat, decitabine, azacitidine, guadecitabine, Quizartinib, Sorafenib, Sunitinib, Lestaurtinib, ABT-737, Navitoclax, Venetoclax, Obatoclax, Nutlin-3A, dasatinib, imatinib, JQ1, GSK1210151A, MS 436, GSK525762, OTX-015, CPI-203, GSK1324726A, daunorubicin, doxorubicin, idarubicin, arsenic trioxide, hydroxyurea, and pharmaceutically acceptable salts thereof.
 3. The combination according to claim 1 or 2 comprising a compound of formula (I):

or a pharmaceutically acceptable salt thereof, and one or more therapeutic agents selected from tretinoin, cytarabine, pinometostat, EPZ-00477, Vorinostat, Ricolinostat, Entinostat, decitabine, azacitidine, Quizartinib, ABT-737, Nutlin-3A, dasatinib, JQ1, daunorubicin, arsenic trioxide, hydroxyurea, and pharmaceutically acceptable salts thereof.
 4. The combination according to claim 1 comprising a compound of formula (I):

or a pharmaceutically acceptable salt thereof, and a retinoic acid analogue or a pharmaceutically acceptable salt thereof.
 5. The combination according to claim 4, wherein the retinoic acid analogue is tretinoin or a pharmaceutically acceptable salt thereof.
 6. The combination according to claim 1 comprising a compound of formula (I):

or a pharmaceutically acceptable salt thereof, and a nucleoside analogue or a pharmaceutically acceptable salt thereof.
 7. The combination according to claim 6, wherein the nucleoside analogue is cytarabine or a pharmaceutically acceptable salt thereof.
 8. The combination according to claim 1 comprising a compound of formula (I):

or a pharmaceutically acceptable salt thereof, and a DOT1L inhibitor or a pharmaceutically acceptable salt thereof.
 9. The combination according to claim 8, wherein the DOT1L inhibitor is pinometostat, EPZ-004777 or SGC-0946, or a pharmaceutically acceptable salt thereof.
 10. The combination according to claim 1 comprising a compound of formula (I):

or a pharmaceutically acceptable salt thereof, and an HDAC inhibitor or a pharmaceutically acceptable salt thereof.
 11. The combination according to claim 10, wherein the HDAC inhibitor is Belinostat, Panobinostat, Vorinostat, Ricolinostat, Entinostat, Mocetinostat, Abexinostat, Resminostat, Givinostat, Quisinostat, or a pharmaceutically acceptable salt thereof.
 12. The combination according to claim 1 comprising a compound of formula (I):

or a pharmaceutically acceptable salt thereof, and a demethylating agent or a pharmaceutically acceptable salt thereof.
 13. The combination according to claim 12, wherein the demethylating agent is decitabine or azacitidine, or a pharmaceutically acceptable salt thereof.
 14. The combination according to claim 1 comprising a compound of formula (I):

or a pharmaceutically acceptable salt thereof, and an FLT3 inhibitor or a pharmaceutically acceptable salt thereof.
 15. The combination according to claim 14, wherein the FLT3 inhibitor is Quizartinib, Sorafenib, Sunitinib and Lestaurtinib, or a pharmaceutically acceptable salt thereof.
 16. The combination according to claim 1 comprising a compound of formula (I):

or a pharmaceutically acceptable salt thereof, and a BCL2 inhibitor or a pharmaceutically acceptable salt thereof.
 17. The combination according to claim 16, wherein the BCL2 inhibitor is ABT-737, Navitoclax, Venetoclax, Obatoclax, or a pharmaceutically acceptable salt thereof.
 18. The combination according to claim 1 comprising a compound of formula (I):

or a pharmaceutically acceptable salt thereof, and a MDM2 inhibitor or a pharmaceutically acceptable salt thereof.
 19. The combination according to claim 18, wherein the MDM2 inhibitor is Nutlin-3A, or a pharmaceutically acceptable salt thereof.
 20. The combination according to claim 1 comprising a compound of formula (I):

or a pharmaceutically acceptable salt thereof, and a c-KIT inhibitor or a pharmaceutically acceptable salt thereof.
 21. The combination according to claim 20, wherein the c-KIT inhibitor is dasatinib or imatinib, or a pharmaceutically acceptable salt thereof.
 22. The combination according to claim 1 comprising a compound of formula (I):

or a pharmaceutically acceptable salt thereof, and a BET inhibitor or a pharmaceutically acceptable salt thereof.
 23. The combination according to claim 22, wherein the BET inhibitor is JQ1, GSK1210151A, MS 436, GSK525762, OTX-015, CPI-203, GSK1324726A, or a pharmaceutically acceptable salt thereof.
 24. The combination according to claim 1, comprising a compound of formula (I):

or a pharmaceutically acceptable salt thereof, and an anthracycline or a pharmaceutically acceptable salt thereof.
 25. The combination according to claim 24, wherein the anthracycline is daunorubicin, idarubicin, or a pharmaceutically acceptable salt thereof.
 26. The combination according to claim 25, which further comprises cytarabine, or a pharmaceutically acceptable salt thereof.
 27. The combination according to claim 1 comprising a compound of formula (I):

or a pharmaceutically acceptable salt thereof, and arsenic trioxide.
 28. The combination according to claim 1 comprising a compound of formula (I):

or a pharmaceutically acceptable salt thereof, and hydroxyurea.
 29. A pharmaceutical composition comprising a combination according to any one of claims 1 to 28 and one or more pharmaceutically acceptable excipients.
 30. An article of manufacture comprising a combination according to any of claims 1 to 28 useful in the treatment of a hematological malignancy.
 31. A combination according to any one of claims 1 to 28 for use as therapeutically active substance.
 32. A combination according to any one of claims 1 to 28 for use in the treatment of a hematological malignancy.
 33. A method for the treatment of hematological malignancy in a patient in need thereof, which method comprises administering a therapeutically effective amount of a combination according to any of claims 1 to 28 to said patient.
 34. A method for the treatment of a hematological malignancy in a patient in need thereof, which method comprises administering the pharmaceutical composition according to claim 29 to said patient.
 35. A use of a combination according to any one of claims 1 to 28 for the treatment of a hematological malignancy.
 36. A use of a combination according to any one of claims 1 to 28 for the preparation of a medicament useful in the treatment of a hematological malignancy.
 37. The article of manufacture of claim 30, the combination of claim 32, the method of claim 33 or 34, or the use of claim 35 or 36, wherein the hematological malignancy is a myeloid hematological malignancy.
 38. The article of manufacture of claim 37, the combination of claim 37, the methods of claim 37, or the uses of claim 37, wherein the myeloid hematological malignancy is acute myeloid leukemia.
 39. The article of manufacture of claim 37, the combination of claim 37, the methods of claim 37, or the uses of claim 37, wherein the myeloid hematological malignancy is chronic myelogenus leukemia.
 40. The article of manufacture of claim 37, the combination of claim 37, the methods of claim 37, or the uses of claim 37, wherein the myeloid hematological malignancy is myelodysplastic syndrome.
 41. The article of manufacture of claim 37, the combination of claim 37, the methods of claim 37, or the uses of claim 37, wherein the myeloid hematological malignancy is a myeloproliferative disease.
 42. The article of manufacture of claim 37, the combination of claim 37, the methods of claim 37, or the uses of claim 37, wherein the myeloproliferative disease is selected from the group consisting of myelofibrosis, acute biphenotypic leukemia, Polycythemia vera, Chronic eosinophilic leukemia/Hypereosinophilic syndrome, Essential thrombocytosis, and Chronic eosinophilic leukemia/Hypereosinophilic syndrome.
 43. The article of manufacture of claim 37, the combination of claim 37, the methods of claim 37, or the uses of claim 37, wherein the myeloid hematological malignancy is a myeloid hematological malignancy with translocation or rearrangements involving MLL, AF9, AF4, AF10, AML1, ETO, CALM; or mutation in NPM1 or Notch1, or LSD1 overexpression.
 44. The article of manufacture of claim 30, the combination of claim 32, the method of claim 33 or 34, or the use of claim 35 or 36, wherein the hematological malignancy is a lymphoid hematological malignancy.
 45. The article of manufacture of claim 44, the combination of claim 44, the methods of claim 44, or the uses of claim 44, wherein the lymphoid hematological malignancy is acute lymphoblastic leukemia.
 46. The article of manufacture of claim 44, the combination of claim 44, the methods of claim 44, or the uses of claim 44, wherein the lymphoid hematological malignancy is a lymphoid hematological malignancy with translocation or rearrangements involving MLL, AF9, AF4, AF10, AML1, ETO, CALM; or mutation in NPM1 or Notch1, or LSD1 overexpression.
 47. The method of any one of claims 33, 34 or 37 to 46, wherein the patient is a human being.
 48. The invention as hereinbefore described. 